Basic Information
Provider Information | |||||||||
NPI: | 1124223565 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLDT | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | WARREN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5767 W CENTURY BLVD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900455631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 757 WESTWOOD PLZ STE 3325 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900950001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3102678642 | ||||||||
FaxNumber: | 3102673899 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2007 | ||||||||
LastUpdateDate: | 12/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/23/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 1124223565 | CA | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 208600000X | A117430 | CA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0102X | A117430 | CA | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 207L00000X | A117430 | CA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.