Provider Demographics
NPI: | 1013937853 |
---|---|
Name: | BOLTIN, CAROLYN MIRA (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CAROLYN |
Middle Name: | MIRA |
Last Name: | BOLTIN |
Suffix: | |
Gender: | F |
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: | 525 E 68TH ST # 141 |
Mailing Address - Street 2: | |
Mailing Address - City: | NEW YORK |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 10065-4870 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 212-746-2630 |
Mailing Address - Fax: | 714-571-5055 |
Practice Address - Street 1: | 525 E 68TH ST DEPT OF |
Practice Address - Street 2: | |
Practice Address - City: | NEW YORK |
Practice Address - State: | NY |
Practice Address - Zip Code: | 10065-4870 |
Practice Address - Country: | US |
Practice Address - Phone: | 646-456-4333 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-21 |
Last Update Date: | 2023-09-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NY | 221744-1 | 2085R0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
000A961420 | Other | BLUE SHIELD OF CA | |
050396C161340 | Other | TRAILBLAZER | |
CA | 00A961420 | Medicaid | |
P00384787 | Other | RAILROAD MEDICARE | |
CA | 00A961420 | Medicaid | |
000A961420 | Other | BLUE SHIELD OF CA |