Provider Demographics
NPI:1457523987
Name:BOLOS, PETER R (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:R
Last Name:BOLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 MERRY WATER DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33548-4807
Mailing Address - Country:US
Mailing Address - Phone:813-477-9979
Mailing Address - Fax:888-688-1659
Practice Address - Street 1:1208 MERRY WATER DR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33548-4807
Practice Address - Country:US
Practice Address - Phone:813-477-9979
Practice Address - Fax:888-688-1659
Is Sole Proprietor?:No
Enumeration Date:2008-03-25
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4339142085R0202X
MDD805912085R0202X
FLME1040232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009111600Medicaid
FL14N46OtherBLUE CROSS
FL009111600Medicaid