Provider Demographics
NPI:1174563043
Name:BOLIN, JERRY BLAKE (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:BLAKE
Last Name:BOLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J BLAKE
Other - Middle Name:
Other - Last Name:BOLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:3550 PARKWOOD BLVD.
Mailing Address - Street 2:BLDG. D. STE. 405
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034
Mailing Address - Country:US
Mailing Address - Phone:469-287-8800
Mailing Address - Fax:469-287-8801
Practice Address - Street 1:3550 PARKWOOD BLVD.
Practice Address - Street 2:BLDG. D, STE. 405
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034
Practice Address - Country:US
Practice Address - Phone:469-287-8800
Practice Address - Fax:469-287-8801
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8512J0Medicare Oscar/Certification
H05483Medicare UPIN