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General NPI Number Information
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NPI Number | 1255344388
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Entity Type | Individual
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Provider Name | MARK RICHARD BOLSTEIN O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/13/2006
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Last Update Date | 11/01/2010
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Provider Practice Location Address
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Address Line | 600 MONTGOMERY MALL
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City | NORTH WALES
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State | PA
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Zip | 19454-3912
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Country | US
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Telephone | 215-361-8282
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Fax | 215-362-0528
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Provider Business Mailing Address
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Address Line | 686 MISTY HOLLOW DR
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City | MAPLE GLEN
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State | PA
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Zip | 19002-2335
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Country | US
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Telephone | 215-283-2565
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Fax | 215-362-0528
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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 | OET008974
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License Number State | PA
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