Provider Demographics
NPI:1407060189
Name:BOLKHIR, WESAM A (MD)
Entity type:Individual
Prefix:DR
First Name:WESAM
Middle Name:A
Last Name:BOLKHIR
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 1:100 MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-1366
Mailing Address - Country:US
Mailing Address - Phone:636-625-5200
Mailing Address - Fax:
Practice Address - Street 1:50 UNION ST
Practice Address - Street 2:
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1534
Practice Address - Country:US
Practice Address - Phone:207-664-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48702207R00000X, 208M00000X
WV23943207R00000X
MEMD22886208M00000X
TN52862207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35.130818OtherSTATE LICENSE
IN0L025959AOtherSTATE LICENSE
WV23943OtherSTATE LICENSE
NC2015-02417OtherSTATE LICENSE
MO2015039932OtherSTATE LICENSE
AL04-41536OtherSTATE LICENSE
TXQ7150OtherSTATE LICENSE
TN52862OtherSTATE LICENSE
PAMD455359OtherSTATE LICENSE
FLME124779OtherSTATE LICENSE
VA0101259122OtherSTATE LICENSE
KY48702OtherSTATE LICENSE
AZ51128OtherSTATE LICENSE
MEMD22886OtherSTATE LICENSE