Provider Demographics
NPI:1073019261
Name:BOLDT, BRANDON FORREST (MD)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:FORREST
Last Name:BOLDT
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 1:43 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:RI
Mailing Address - Zip Code:02841-1006
Mailing Address - Country:US
Mailing Address - Phone:401-841-7987
Mailing Address - Fax:
Practice Address - Street 1:293 KOLLMEYER ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02841-1605
Practice Address - Country:US
Practice Address - Phone:401-841-7987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD-46469207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine