Provider Demographics
NPI:1588692388
Name:BOLTON, PHILIP MANNING (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:MANNING
Last Name:BOLTON
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:PO BOX 19134
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97280-0134
Mailing Address - Country:US
Mailing Address - Phone:503-245-5142
Mailing Address - Fax:
Practice Address - Street 1:6400 SE LAKE RD STE 325
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2185
Practice Address - Country:US
Practice Address - Phone:503-786-1711
Practice Address - Fax:503-786-9919
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD200922084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226895OtherOMAP PROVIDER #
OR226895OtherOMAP PROVIDER #
104504Medicare ID - Type UnspecifiedPROVIDER IDENTIFICATION #
ORG97470Medicare UPIN