Basic Information
| Provider Information | |||||||||
| NPI: | 1477578698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLIVAR | ||||||||
| FirstName: | ALVARO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 598 N F ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098888152 | ||||||||
| FaxNumber: | 9098847530 | ||||||||
| Practice Location | |||||||||
| Address1: | 598 N F ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098888152 | ||||||||
| FaxNumber: | 9098847530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 12/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A38312 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A383120 | 05 | CA | MEDICAID |