Provider Demographics
NPI:1063400893
Name:BOLOCZKO, SYLVIA (MD)
Entity type:Individual
Prefix:
First Name:SYLVIA
Middle Name:
Last Name:BOLOCZKO
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 1:16860 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6713
Mailing Address - Country:US
Mailing Address - Phone:352-432-8443
Mailing Address - Fax:844-388-6186
Practice Address - Street 1:16860 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6713
Practice Address - Country:US
Practice Address - Phone:352-432-8443
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME151089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4543980Medicaid
MIC56012013Medicare ID - Type Unspecified
H97992Medicare UPIN