Provider Demographics
NPI:1770566366
Name:BOLES, DONALD J JR (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:J
Last Name:BOLES
Suffix:JR
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 1:1928 E STEPHENS DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-4912
Mailing Address - Country:US
Mailing Address - Phone:480-838-3100
Mailing Address - Fax:
Practice Address - Street 1:6301 S MCCLINTOCK DR
Practice Address - Street 2:STE MC201
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3392
Practice Address - Country:US
Practice Address - Phone:480-838-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD43717Medicare UPIN
AZ81972Medicare PIN