Individual
DIANE BOLDUC
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
340 MEDICAL LOOP, ROSEBURG, OR 97470-1645
(541) 464-5907
(541) 464-8481
Mailing address
340 MEDICAL LOOP, ROSEBURG, OR 97470-1645
(541) 464-5907
(541) 464-8481
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD23487
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
287185
—
OR
01
—
32945700000
PROVIDENCE HEALTH PLANS
—
01
—
608828900
BLACK LUNG FEDERAL PROGRA
—
01
—
840254000
REGENCE BLUE CROSS
OR
01
—
J103601
PACIFIC SOURCE
OR
Enumeration date
07/28/2006
Last updated
07/09/2007
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