Provider Demographics
NPI:1316126444
Name:BOLDON, KEITH C (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:C
Last Name:BOLDON
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 1:391 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-5844
Mailing Address - Country:US
Mailing Address - Phone:203-238-1555
Mailing Address - Fax:203-634-0533
Practice Address - Street 1:435 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2101
Practice Address - Country:US
Practice Address - Phone:203-694-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043896207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1316126444Medicaid
CT050001685Medicare PIN