Provider Demographics
NPI:1801830609
Name:BOLIVAR, DAVID ALFONSO (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ALFONSO
Last Name:BOLIVAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:598 N F ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-3110
Mailing Address - Country:US
Mailing Address - Phone:951-351-1600
Mailing Address - Fax:951-351-9402
Practice Address - Street 1:18300 HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307
Practice Address - Country:US
Practice Address - Phone:760-242-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33373207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A333730Medicaid
CA00A333732Medicaid
CAA87849Medicare UPIN
CA00A333730Medicaid