MEDICARE: DR. VICTORIA BOLYARD O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1897	SC
2	152W00000X	Optometrist	046010814	IL

General Provider Information

NPI Number	:	1205240124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VICTORIA BOLYARD O.D.

Provider Business Mailing Address
First Line	:	1312 MOSSY RD
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-3843
Country	:	US
Telephone Number	:	773-334-1893
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 W BRYN MAWR AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-4691
Country	:	US
Telephone Number	:	773-334-1893
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2014
Last Update Date	:	05/31/2021

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