Basic Information
| Provider Information | |||||||||
| NPI: | 1992798433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOLICK | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7413 SIX FORKS RD | ||||||||
| Address2: | #144 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Practice Location | |||||||||
| Address1: | 7413 SIX FORKS RD | ||||||||
| Address2: | #144 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276156164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198470187 | ||||||||
| FaxNumber: | 9196762231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 12/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0959 | NC | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 09111 | 01 | NC | BLUECROSS | OTHER | 410048143 | 01 | NC | RAILROAD MEDICARE | OTHER | 8909111 | 05 | NC | MEDICAID |