Provider Demographics
NPI:1891807459
Name:BOLTE, BRETT J (MD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:J
Last Name:BOLTE
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 1:2115 N 34TH ST
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3114
Mailing Address - Country:US
Mailing Address - Phone:254-753-1885
Mailing Address - Fax:254-755-0078
Practice Address - Street 1:2115 N 34TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3114
Practice Address - Country:US
Practice Address - Phone:254-753-1885
Practice Address - Fax:254-755-0078
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9301208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE82513Medicare UPIN
TXOOG14L88K571Medicare ID - Type Unspecified