Provider Demographics
NPI:1124082458
Name:BOLSTAD, MARGOT R (DO)
Entity type:Individual
Prefix:
First Name:MARGOT
Middle Name:R
Last Name:BOLSTAD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 E 12TH ST
Mailing Address - Street 2:PO BOX 1520
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3213
Mailing Address - Country:US
Mailing Address - Phone:541-296-9151
Mailing Address - Fax:541-296-4710
Practice Address - Street 1:65371 WA-14
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-9867
Practice Address - Country:US
Practice Address - Phone:509-493-2133
Practice Address - Fax:509-493-9544
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO14331208D00000X
WAOP60910561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR125286Medicaid
OR125286Medicaid
C90849Medicare UPIN
OR110133Medicare ID - Type Unspecified