Provider Demographics
NPI:1972620797
Name:BOLTON, GARY GLENN (M D)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:GLENN
Last Name:BOLTON
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HIGHLAND PARK CV
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6059
Mailing Address - Country:US
Mailing Address - Phone:601-206-9433
Mailing Address - Fax:601-206-5428
Practice Address - Street 1:305 HIGHLAND PARK CV
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6059
Practice Address - Country:US
Practice Address - Phone:601-206-9433
Practice Address - Fax:601-206-5428
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10243207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00111886Medicaid
E27688Medicare UPIN
MS00111886Medicaid