Basic Information
Provider Information | |||||||||
NPI: | 1497717748 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOLLYKY | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BEART | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1804 EMBARCADERO RD | ||||||||
Address2: | STE 100 | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943033318 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6507234000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 300 PASTEUR DR | ||||||||
Address2: |   | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943042203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6507234000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2006 | ||||||||
LastUpdateDate: | 05/23/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00044340 | WA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | C55872 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00188398 | 01 | WA | RAILROAD MEDICARE | OTHER | 8415879 | 05 | WA |   | MEDICAID | 0192575 | 01 | WA | L & I WORKERS COMP | OTHER | 3536BO | 01 | WA | REGENCE BLUESHIELD RIDER | OTHER |