Provider Demographics
NPI:1134195464
Name:BOLT, MICHAEL S (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:BOLT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1851 N WEBB RD
Mailing Address - Street 2:FLOOR 2
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208
Mailing Address - Country:US
Mailing Address - Phone:316-636-2010
Mailing Address - Fax:316-858-3830
Practice Address - Street 1:834 N SOCORA
Practice Address - Street 2:STE 2
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212
Practice Address - Country:US
Practice Address - Phone:316-722-8883
Practice Address - Fax:316-721-4864
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS0421978207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B69315Medicare UPIN
KS040560Medicare ID - Type Unspecified