Provider Demographics
NPI:1558320119
Name:BOLEMAN, WILLIAM TODD (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:TODD
Last Name:BOLEMAN
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 1:690 DALLAS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1264
Mailing Address - Country:US
Mailing Address - Phone:770-459-0620
Mailing Address - Fax:770-456-7604
Practice Address - Street 1:690 DALLAS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1264
Practice Address - Country:US
Practice Address - Phone:770-459-0620
Practice Address - Fax:770-456-7604
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-050257-L207K00000X, 208000000X
GA068372207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicaid
GAPENDINGMedicaid