MEDICARE: DR. MICHAEL SCOTT BOLD OD

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	COR905	CA

General Provider Information

NPI Number	:	1346349909
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL SCOTT BOLD OD

Provider Business Mailing Address
First Line	:	5422 LA PALMA AVE
Second Line	:
City	:	LA PALMA
State	:	CA
Zip	:	90623-1705
Country	:	US
Telephone Number	:	714-995-1144
Fax Number	:	714-995-7979

Provider Business Practice Location Address
First Line	:	2628 SAN MIGUEL DR
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-5437
Country	:	US
Telephone Number	:	949-644-0165
Fax Number	:	949-644-7762

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	09/13/2018

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