Provider Demographics
NPI:1255342358
Name:BOLES, DAVID L SR (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:BOLES
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 30459
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040
Mailing Address - Country:US
Mailing Address - Phone:931-245-1150
Mailing Address - Fax:931-245-0605
Practice Address - Street 1:1011 HIGHWAY 76 STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2531
Practice Address - Country:US
Practice Address - Phone:931-245-1150
Practice Address - Fax:931-245-0605
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO647207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3391811Medicaid
TN3391811Medicaid
TN3301811Medicare PIN