Provider Demographics
NPI:1871850917
Name:BOLDT, MICHAEL ROY
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROY
Last Name:BOLDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-585-5505
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:3130 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2399
Practice Address - Country:US
Practice Address - Phone:513-584-3999
Practice Address - Fax:513-584-4111
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.129020207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program