Basic Information
| Provider Information | |||||||||
| NPI: | 1710966718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOHLE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362772000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 JOHNSON RIDGE MEDICAL PARK | ||||||||
| Address2: | |||||||||
| City: | ELKIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286212400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 35270 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 35270 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 16435 | 01 | NC | BCBS ID# | OTHER | 8916435 | 05 | NC | MEDICAID | 10533 | 01 | NC | PARTNERS ID# | OTHER | 1285682310 | 01 | NC | WSCA GRP NPI # | OTHER | 1710966718 | 05 | VA | MEDICAID |