Provider Demographics
NPI:1457336497
Name:BOLOTIN, TODD S (MD)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:S
Last Name:BOLOTIN
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 1:5700 DARROW RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5021
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:6252 MAHONING AVE
Practice Address - Street 2:
Practice Address - City:AUSTINTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-2003
Practice Address - Country:US
Practice Address - Phone:330-792-7418
Practice Address - Fax:330-792-9092
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35060979B207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000349348OtherANTHEM
OH0858433Medicaid
OH000000028430OtherANTHEM
OH001522135-0005OtherPENNSYLVANIA MEDICAID
OH000000381140OtherANTHEM
OH001522135-0005OtherPENNSYLVANIA MEDICAID
F47365Medicare UPIN
OH0858433Medicaid
OH000000028430OtherANTHEM
OHBO0790537Medicare PIN
OHP00390102Medicare PIN