Basic Information
| Provider Information | |||||||||
| NPI: | 1902998511 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLES | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6430 W SUNSET BLVD | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900287901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612337 | ||||||||
| FaxNumber: | 3233618491 | ||||||||
| Practice Location | |||||||||
| Address1: | 4650 W SUNSET BLVD | ||||||||
| Address2: | MS# 90 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900276062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3233612178 | ||||||||
| FaxNumber: | 3233615937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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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 | 207SG0201X | G65717 | CA | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 00G657170 G79 | 01 | CA | CAL OPTIMA | OTHER | 00G6571710 | 05 | CA | MEDICAID |