Provider Demographics
NPI:1871596379
Name:BOLES, SHAFE D (MD)
Entity type:Individual
Prefix:DR
First Name:SHAFE
Middle Name:D
Last Name:BOLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:S.
Other - Middle Name:DAVID
Other - Last Name:BOLES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2780 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-5442
Mailing Address - Country:US
Mailing Address - Phone:270-926-4100
Mailing Address - Fax:270-648-4678
Practice Address - Street 1:2780 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-5442
Practice Address - Country:US
Practice Address - Phone:270-926-4100
Practice Address - Fax:270-648-4678
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY37532207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000226231OtherANTHEM
KY64051998Medicaid
KYK005560OtherTRICARE
KY200044474OtherRAILROAD MEDICARE
KYK005560OtherTRICARE
KY000000226231OtherANTHEM