Provider Demographics
NPI:1184698219
Name:BOLTON, GABRIELLE (MD)
Entity type:Individual
Prefix:DR
First Name:GABRIELLE
Middle Name:
Last Name:BOLTON
Suffix:
Gender:F
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:PO BOX 28064
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-8064
Mailing Address - Country:US
Mailing Address - Phone:914-593-7880
Mailing Address - Fax:914-593-7881
Practice Address - Street 1:15 N BROADWAY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-2214
Practice Address - Country:US
Practice Address - Phone:914-428-6000
Practice Address - Fax:914-593-7881
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110227809OtherRAIL ROAD MEDICARE
NY01120736Medicaid
NY18G763K223OtherPTAN
NY01120736Medicaid
NYA400061894Medicare PIN
NY01120736Medicaid