1922159169 NPI number — DR. CARL DAVID BOLLINGER O.D.

Table of content: DR. CARL DAVID BOLLINGER O.D. (NPI 1922159169)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922159169 NPI number — DR. CARL DAVID BOLLINGER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOLLINGER
Provider First Name:
CARL
Provider Middle Name:
DAVID
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922159169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 127
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEMMONS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27012-0127
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-766-7373
Provider Business Mailing Address Fax Number:
336-766-7382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6301 STADIUM DR
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
CLEMMONS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27012-8766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-766-7373
Provider Business Practice Location Address Fax Number:
336-766-7382
Provider Enumeration Date:
01/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1020 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 561282758 . This is a "AETNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 917812 . This is a "EYEMED VISION CARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 13283 . This is a "SPECTERA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0952390001 . This is a "PALMETTO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 09114 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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