Provider Demographics
NPI:1982629838
Name:BOLEN, JOHN W (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:BOLEN
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 1:1100 9TH AVE
Mailing Address - Street 2:MS M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:206-583-6025
Mailing Address - Fax:206-515-5886
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016100207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD6100WOtherALASKA MEDICAID
220013529OtherRAILROAD MEDICARE
WA0039575OtherLABOR & INDUSTRY
WA804194900OtherIDAHO MEDICAID
WA8381204Medicaid
WAUS0861403OtherAETNA/USHC SPECIALIST
WAB460OtherBLUE SHIELD
WA0039575OtherLABOR & INDUSTRY
A04110Medicare UPIN