Provider Demographics
NPI:1770548315
Name:BOLAND, ROBERT J (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
Last Name:BOLAND
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 1:12301 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-6207
Mailing Address - Country:US
Mailing Address - Phone:713-275-5400
Mailing Address - Fax:
Practice Address - Street 1:12301 MAIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77035-6207
Practice Address - Country:US
Practice Address - Phone:713-275-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX472502084P0800X
RIMD081992084P0800X
MA2607072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30526-4OtherBCBS RI
RI203058OtherBLUECHIP
RI9006671Medicaid
G63121Medicare UPIN
RI007056456Medicare PIN