Basic Information
Provider Information | |||||||||
NPI: | 1386643831 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLAN | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | KEY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1625 SCHRADER BLVD FL 3 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900286213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3239937500 | ||||||||
FaxNumber: | 3233084015 | ||||||||
Practice Location | |||||||||
Address1: | 1625 SCHRADER BLVD | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900286213 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3239937500 | ||||||||
FaxNumber: | 3233084015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2005 | ||||||||
LastUpdateDate: | 02/08/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | G39301 | CA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | G39301 | 01 | CA | STATE LICENSE # | OTHER | 00G393010 | 05 | CA |   | MEDICAID |