Provider Demographics
NPI:1902998958
Name:BOLTON, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:BOLTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:306 N FERNDALE AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3421
Mailing Address - Country:US
Mailing Address - Phone:415-383-5553
Mailing Address - Fax:415-383-5553
Practice Address - Street 1:306 N FERNDALE AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3421
Practice Address - Country:US
Practice Address - Phone:415-383-5553
Practice Address - Fax:415-383-5553
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC30015208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics