Provider Demographics
NPI:1033157417
Name:BOLEN, TERRY L (OD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:L
Last Name:BOLEN
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:PO BOX 122
Mailing Address - Street 2:
Mailing Address - City:HEWITT
Mailing Address - State:TX
Mailing Address - Zip Code:76643-0122
Mailing Address - Country:US
Mailing Address - Phone:254-339-1000
Mailing Address - Fax:
Practice Address - Street 1:600 HEWITT DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6654
Practice Address - Country:US
Practice Address - Phone:254-339-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist