Provider Demographics
NPI:1538161492
Name:BOLES, BONNIE KRISTINE (MD)
Entity type:Individual
Prefix:
First Name:BONNIE
Middle Name:KRISTINE
Last Name:BOLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:119 AMBULANCE DRIVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-1476
Mailing Address - Country:US
Mailing Address - Phone:770-456-3380
Mailing Address - Fax:770-456-3785
Practice Address - Street 1:690 DALLAS HWY
Practice Address - Street 2:SUITE 207-A
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1264
Practice Address - Country:US
Practice Address - Phone:770-456-3380
Practice Address - Fax:770-456-3785
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA036927207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000682437HMedicaid
GA000682437FMedicaid
GA000682437HMedicaid
GA000682437FMedicaid