Healthcare Provider Details

I. General information

NPI: 1629094313
Provider Name (Legal Business Name): ROBERT J BOLDUC JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ALFRED ST
BIDDEFORD ME
04005-3127
US

IV. Provider business mailing address

311 ALFRED ST
BIDDEFORD ME
04005-3127
US

V. Phone/Fax

Practice location:
  • Phone: 207-284-6651
  • Fax:
Mailing address:
  • Phone: 207-284-6651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number660T
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: