Provider Demographics
NPI:1023305687
Name:BOLER, MICHAEL TED JR (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:TED
Last Name:BOLER
Suffix:JR
Gender:M
Credentials:DO
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Mailing Address - Street 1:499 GLOSTER CREEK VLG STE A2
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4749
Mailing Address - Country:US
Mailing Address - Phone:662-620-6800
Mailing Address - Fax:662-620-6950
Practice Address - Street 1:499 GLOSTER CREEK VLG STE A2
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4749
Practice Address - Country:US
Practice Address - Phone:662-620-6800
Practice Address - Fax:662-620-6950
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2019-07-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS23370207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST-2411OtherTEMP. MEDICAL LICENSE NUMBER