Provider Demographics
NPI:1194745497
Name:BOLTON, KIRSTEN J (MD)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:J
Last Name:BOLTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1308
Mailing Address - Street 2:
Mailing Address - City:SALTILLO
Mailing Address - State:MS
Mailing Address - Zip Code:38866-1308
Mailing Address - Country:US
Mailing Address - Phone:662-869-0033
Mailing Address - Fax:662-869-0053
Practice Address - Street 1:2781 HIGHWAY 145
Practice Address - Street 2:
Practice Address - City:SALTILLO
Practice Address - State:MS
Practice Address - Zip Code:38866-9783
Practice Address - Country:US
Practice Address - Phone:662-869-0033
Practice Address - Fax:662-869-0053
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120764Medicaid
MSG97461Medicare UPIN
MS00120764Medicaid