Provider Demographics
NPI:1003831371
Name:BOLLIN, NICHOLAS R (OD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:R
Last Name:BOLLIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4720 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6292
Mailing Address - Country:US
Mailing Address - Phone:912-354-4800
Mailing Address - Fax:912-629-5821
Practice Address - Street 1:4720 WATERS AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6292
Practice Address - Country:US
Practice Address - Phone:912-354-4800
Practice Address - Fax:912-629-5821
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1463152W00000X
GAOPT002419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00684230OtherRAILROAD MEDICARE PTAN
GA511I410154OtherMEDICARE PTAN
SC6830OtherMEDICARE GROUP NUMBER
GA895091476FMedicaid
SCDA9680OtherMEDICAID GROUP NUMBER
GA511G701032OtherMEDICARE GROUP
GA895091476DMedicaid
SCD14633Medicaid
SCAA62946830OtherMEDICARE PTAN
GA895091476FMedicaid
GA895091476DMedicaid
SCAA62946830OtherMEDICARE PTAN