Provider Demographics
NPI:1740488196
Name:BOLITHO, DOUGLAS GLYNN (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:GLYNN
Last Name:BOLITHO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9834 GENESEE AVE
Mailing Address - Street 2:311
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1223
Mailing Address - Country:US
Mailing Address - Phone:858-458-5100
Mailing Address - Fax:858-458-1550
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:311
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-458-5100
Practice Address - Fax:858-458-1550
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA69572208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH29631Medicare UPIN