Provider Demographics
NPI:1699734855
Name:BOLES, PRESTON (DPM)
Entity type:Individual
Prefix:DR
First Name:PRESTON
Middle Name:
Last Name:BOLES
Suffix:
Gender:M
Credentials:DPM
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 1410
Mailing Address - Street 2:CLINIC ADMINISTRATION
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1410
Mailing Address - Country:US
Mailing Address - Phone:662-459-7189
Mailing Address - Fax:
Practice Address - Street 1:309 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4305
Practice Address - Country:US
Practice Address - Phone:662-453-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80105213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00015222Medicaid
MSP00391905OtherMEDICARE RAILROAD