Basic Information
| Provider Information | |||||||||
| NPI: | 1184698219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLTON | ||||||||
| FirstName: | GABRIELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 28064 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100878064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9145937880 | ||||||||
| FaxNumber: | 9145937881 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 N BROADWAY | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106012214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144286000 | ||||||||
| FaxNumber: | 9145937881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 10/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 119650 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110227809 | 01 | NY | RAIL ROAD MEDICARE | OTHER | 01120736 | 05 | NY | MEDICAID | 18G763K223 | 01 | NY | PTAN | OTHER |