Provider Demographics
NPI:1669415303
Name:BOLTWOOD, CHESTER MCBRIDE JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHESTER
Middle Name:MCBRIDE
Last Name:BOLTWOOD
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4601 DALE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9718
Mailing Address - Country:US
Mailing Address - Phone:209-735-4287
Mailing Address - Fax:209-735-4283
Practice Address - Street 1:4603 DALE RD
Practice Address - Street 2:KAISER PERMANENTE MEDICAL OFFICES
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95357-7680
Practice Address - Country:US
Practice Address - Phone:209-735-4287
Practice Address - Fax:209-735-4283
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35042207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76734ZMedicaid
CAZZZ76734ZMedicaid
CAZZZ76734ZMedicare ID - Type Unspecified