Provider Demographics
NPI:1851686372
Name:BOLIN, MATTHEW BARRY (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BARRY
Last Name:BOLIN
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 1:5604 STAR FLOWER DR
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840-8693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 N CLIPPERT ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-4701
Practice Address - Country:US
Practice Address - Phone:517-999-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301111245207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program