Provider Demographics
NPI:1265616007
Name:BOLDEN, KELLY MICHELLE (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHELLE
Last Name:BOLDEN
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 1:4834 BLAGDEN AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-3716
Mailing Address - Country:US
Mailing Address - Phone:202-230-0364
Mailing Address - Fax:
Practice Address - Street 1:5301 WISCONSIN AVE NW STE 100
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-2070
Practice Address - Country:US
Practice Address - Phone:202-237-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0071243208200000X
DCMD040080208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery