Provider Demographics
NPI:1942529730
Name:BOLTON, BRETT (D,O)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:
Last Name:BOLTON
Suffix:
Gender:M
Credentials:D,O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11664
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33339-1664
Mailing Address - Country:US
Mailing Address - Phone:954-567-5868
Mailing Address - Fax:954-567-5869
Practice Address - Street 1:2715 E OAKLAND PARK BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1659
Practice Address - Country:US
Practice Address - Phone:954-567-5868
Practice Address - Fax:954-567-5869
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S0007493208D00000X
TNDO 1256208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice