MEDICARE: DR. ELLESSE BOIWKA O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1857	SC

General Provider Information

NPI Number	:	1306256003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLESSE BOIWKA O.D.

Provider Business Mailing Address
First Line	:	1296 LONG GROVE DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-9462
Country	:	US
Telephone Number	:	843-388-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1296 LONG GROVE DR
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-9462
Country	:	US
Telephone Number	:	843-388-6200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2014
Last Update Date	:	02/16/2021

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