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General NPI Number Information
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NPI Number | 1639241508
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Entity Type | Individual
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Provider Name | GEORGE BOLING O.D.
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Gender | Male
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 835 W JOHNSON ST SPC. C07C FOREST MALL
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City | FOND DU LAC
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State | WI
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Zip | 54935-8297
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Country | US
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Telephone | 920-906-9489
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Fax |
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Provider Business Mailing Address
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Address Line | 161 LAKE SHORE TER
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City | BEAVER DAM
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State | WI
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Zip | 53916-1245
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Country | US
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Telephone | 920-887-2864
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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 | 1570-035
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License Number State | WI
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