Provider Demographics
NPI:1447468624
Name:BOLTAN, DAVID DMITRY (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:DMITRY
Last Name:BOLTAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 N MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2220
Mailing Address - Country:US
Mailing Address - Phone:972-579-8485
Mailing Address - Fax:
Practice Address - Street 1:1901 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2220
Practice Address - Country:US
Practice Address - Phone:972-579-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM8543208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X0058OtherBCBS
TX200691801Medicaid
TX8K7118Medicare PIN
TXP00696093Medicare PIN
TX8L23593Medicare PIN