Provider Demographics
NPI:1962468025
Name:BOULT, CHARLES E (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:BOULT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-5400
Mailing Address - Fax:208-302-5455
Practice Address - Street 1:5966 W CURTISIAN AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-302-5400
Practice Address - Fax:208-302-5455
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD57945207RG0300X
IDM-13173207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD687003100Medicaid
MDA75692Medicare UPIN