Provider Demographics
NPI:1932184181
Name:BOLTON, TRAVIS L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:L
Last Name:BOLTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5339
Mailing Address - Country:US
Mailing Address - Phone:615-371-5778
Mailing Address - Fax:615-290-5294
Practice Address - Street 1:2400 UNSER BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-4740
Practice Address - Country:US
Practice Address - Phone:505-253-1187
Practice Address - Fax:505-253-1199
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2017-0672207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064450100Medicaid
E62897Medicare UPIN
FL11462YMedicare ID - Type Unspecified