Provider Demographics
NPI:1649284639
Name:BOLO, PETER M (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:BOLO
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 1:99 BEAUVOIR AVENUE
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07902-3533
Mailing Address - Country:US
Mailing Address - Phone:908-522-2226
Mailing Address - Fax:908-522-5269
Practice Address - Street 1:99 BEAUVOIR AVENUE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07902-3533
Practice Address - Country:US
Practice Address - Phone:908-522-2226
Practice Address - Fax:908-522-5269
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA531942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6358802Medicaid
A64726Medicare UPIN
NJ6358802Medicaid