Healthcare Provider Details

I. General information

NPI: 1003296120
Provider Name (Legal Business Name): STEPHEN D. BOLLINGER O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 HIGHWAY K
O FALLON MO
63368-7861
US

IV. Provider business mailing address

514 WARREN COUNTY CTR
WARRENTON MO
63383-3023
US

V. Phone/Fax

Practice location:
  • Phone: 636-240-1516
  • Fax:
Mailing address:
  • Phone: 636-377-2054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2015015577
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: