Provider Demographics
NPI:1922146851
Name:BOLTUCH, ROBERT LEWIS (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:LEWIS
Last Name:BOLTUCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 N MILITARY TRL
Mailing Address - Street 2:SUITE 17
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-2974
Mailing Address - Country:US
Mailing Address - Phone:561-689-2110
Mailing Address - Fax:561-689-2032
Practice Address - Street 1:2695 N MILITARY TRL
Practice Address - Street 2:SUITE 17
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-2974
Practice Address - Country:US
Practice Address - Phone:561-689-2110
Practice Address - Fax:561-689-2032
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS4902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82872Medicare ID - Type Unspecified
FLE32307Medicare UPIN