Healthcare Provider Details

I. General information

NPI: 1730536178
Provider Name (Legal Business Name): MARIE TEKLA ELEANOR WALDROP O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIE TEKLA ELEANOR BOLIN O.D.

II. Dates (important events)

Enumeration Date: 05/16/2016
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5556 SUNSET BLVD
LEXINGTON SC
29072-7989
US

IV. Provider business mailing address

411 TULIP WAY
LEXINGTON SC
29072-6200
US

V. Phone/Fax

Practice location:
  • Phone: 803-265-2744
  • Fax:
Mailing address:
  • Phone: 402-416-4061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number2495
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number4042-35
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1464
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: