Provider Demographics
NPI:1396723581
Name:BOLLA, JOHN
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:BOLLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:SUITE 3803
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5981
Mailing Address - Country:US
Mailing Address - Phone:386-586-1760
Mailing Address - Fax:386-586-1761
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:SUITE 3803
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5981
Practice Address - Country:US
Practice Address - Phone:386-586-1760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0069906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252225000Medicaid
F48872Medicare UPIN
FL252225000Medicaid