Provider Demographics
NPI:1366408999
Name:BOLTON, JEFFREY DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:DAVID
Last Name:BOLTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3511
Mailing Address - Country:US
Mailing Address - Phone:520-399-6000
Mailing Address - Fax:520-399-6002
Practice Address - Street 1:4601 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3511
Practice Address - Country:US
Practice Address - Phone:520-399-6000
Practice Address - Fax:520-399-6002
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8688111N00000X
MI2301006540111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ590722Medicaid
MI2594620Medicaid
MIP52529OtherBLUE CARE NETWORK
MIP52529OtherBLUE CARE NETWORK
MI2594620Medicaid