Individual
OLENA BOLOTOVA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
260 PATCHOGUE YAPHANK RD, EAST PATCHOGUE, NY 11772-4886
(631) 654-8755
Mailing address
1216 HARVARD AVE, YAPHANK, NY 11980-2650
(631) 644-5389
Taxonomy
Speciality
Code
Description
License number
State
207RN0300X
Nephrology Physician
Primary
311738
NY
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A400268620
MEDICARE
NY
Enumeration date
07/21/2016
Last updated
08/22/2021
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