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General NPI Number Information
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NPI Number | 1205240124
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Entity Type | Individual
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Provider Name | VICTORIA BOLYARD O.D.
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Gender | Female
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Dates
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Enumeration Date | 06/18/2014
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Last Update Date | 05/31/2021
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Provider Practice Location Address
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Address Line | 1055 W BRYN MAWR AVE
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City | CHICAGO
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State | IL
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Zip | 60660-4691
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Country | US
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Telephone | 773-334-1893
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Fax |
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Provider Business Mailing Address
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Address Line | 1312 MOSSY RD
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City | MT PLEASANT
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State | SC
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Zip | 29464-3843
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Country | US
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Telephone | 773-334-1893
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1897
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046010814
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License Number State | IL
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