Provider Demographics
NPI:1902999592
Name:BOLTON, MARK EDWIN (PHD, MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:EDWIN
Last Name:BOLTON
Suffix:
Gender:M
Credentials:PHD, MD
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Mailing Address - Street 1:2116 W FAIDLEY AVE.
Mailing Address - Street 2:DEPARTMENT OF RADIATION THERAPY
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-9804
Mailing Address - Country:US
Mailing Address - Phone:308-398-5450
Mailing Address - Fax:308-398-5351
Practice Address - Street 1:2116 W FAIDLEY AVE.
Practice Address - Street 2:DEPARTMENT OF RADIATION THERAPY
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68802-9804
Practice Address - Country:US
Practice Address - Phone:308-398-5450
Practice Address - Fax:308-398-5351
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE187732085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025024800Medicaid
NEF25594Medicare UPIN
NE276835Medicare ID - Type Unspecified