Provider Demographics
NPI:1831278027
Name:BOLDUAN, JEFFREY P (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:P
Last Name:BOLDUAN
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 1:1808 CHARLTON CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6463
Mailing Address - Country:US
Mailing Address - Phone:574-533-8420
Mailing Address - Fax:574-533-3909
Practice Address - Street 1:1808 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6463
Practice Address - Country:US
Practice Address - Phone:574-533-8420
Practice Address - Fax:574-533-3909
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030767208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100112510AMedicaid
IN000000084833OtherANTHEM BLUE CROSS BLUE SHIELD
IN000000084833OtherANTHEM BLUE CROSS BLUE SHIELD
IN100112510AMedicaid