Basic Information
| Provider Information | |||||||||
| NPI: | 1225358369 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLANOS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | GERALD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOLANOS | ||||||||
| OtherFirstName: | RICARDO | ||||||||
| OtherMiddleName: | G | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4352 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145315444 | ||||||||
| FaxNumber: | 3145310063 | ||||||||
| Practice Location | |||||||||
| Address1: | 4352 MANCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631102138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145315444 | ||||||||
| FaxNumber: | 3145310063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207V00000X | 2010020453 | MO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.