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
StateLicense IDTaxonomies
NY221744-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000A961420OtherBLUE SHIELD OF CA
050396C161340OtherTRAILBLAZER
CA00A961420Medicaid
P00384787OtherRAILROAD MEDICARE
CA00A961420Medicaid
000A961420OtherBLUE SHIELD OF CA