Provider Demographics
NPI:1053537852
Name:BOLY, LAWRENCE RAYMOND (MD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:RAYMOND
Last Name:BOLY
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 1:2500 ALHAMBRA AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-3156
Mailing Address - Country:US
Mailing Address - Phone:925-431-2688
Mailing Address - Fax:
Practice Address - Street 1:2500 ALHAMBRA AVE
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-3156
Practice Address - Country:US
Practice Address - Phone:925-431-2688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2015-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG4882502081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51185Medicare UPIN