Basic Information
| Provider Information | |||||||||
| NPI: | 1801830609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOLIVAR | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ALFONSO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 598 N F ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924103110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9513511600 | ||||||||
| FaxNumber: | 9513519402 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602422311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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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 | 207P00000X | A33373 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A333730 | 05 | CA | MEDICAID | 00A333732 | 05 | CA | MEDICAID |