Provider Demographics
NPI:1730155128
Name:BOLTRI, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BOLTRI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 VICTORIA PARK DR
Mailing Address - Street 2:
Mailing Address - City:TALLMADGE
Mailing Address - State:OH
Mailing Address - Zip Code:44278-1574
Mailing Address - Country:US
Mailing Address - Phone:478-714-9345
Mailing Address - Fax:
Practice Address - Street 1:55 ARCH ST STE 3A
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1447
Practice Address - Country:US
Practice Address - Phone:330-375-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.057005207Q00000X
MI4301099774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000502268FMedicaid
GA08BBXCQMedicare ID - Type Unspecified
GAE64960Medicare UPIN
GA000502268FMedicaid