Provider Demographics
NPI:1780757211
Name:BOLDUR, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BOLDUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 EASTERN PKWY
Mailing Address - Street 2:SUITE 1G
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-6085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 EASTERN PKWY
Practice Address - Street 2:SUITE 1G
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-6085
Practice Address - Country:US
Practice Address - Phone:718-636-1182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205589207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH71674Medicare UPIN
NY0105QDMedicare ID - Type Unspecified