MEDICARE: DR. MARK RICHARD BOLSTEIN 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	OET008974	PA

General Provider Information

NPI Number	:	1255344388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK RICHARD BOLSTEIN O.D.

Provider Business Mailing Address
First Line	:	686 MISTY HOLLOW DR
Second Line	:
City	:	MAPLE GLEN
State	:	PA
Zip	:	19002-2335
Country	:	US
Telephone Number	:	215-283-2565
Fax Number	:	215-362-0528

Provider Business Practice Location Address
First Line	:	600 MONTGOMERY MALL
Second Line	:
City	:	NORTH WALES
State	:	PA
Zip	:	19454-3912
Country	:	US
Telephone Number	:	215-361-8282
Fax Number	:	215-362-0528

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

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	11/01/2010

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