Provider Demographics
NPI:1669976023
Name:BOLK, KODY GIBSON (MD)
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:GIBSON
Last Name:BOLK
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 1:533 BOLIVAR ST STE 566
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112-1349
Mailing Address - Country:US
Mailing Address - Phone:504-568-4786
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE STE 1135
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2234
Practice Address - Country:US
Practice Address - Phone:404-778-3381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA95460207Y00000X, 207YX0602X
IL036.170483207Y00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program