Basic Information
| Provider Information | |||||||||
| NPI: | 1316126444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLDON | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 391 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064505844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032381555 | ||||||||
| FaxNumber: | 2036340533 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036948200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 043896 | CT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1316126444 | 05 | CT | MEDICAID |