Provider Demographics
NPI:1043300585
Name:BOLER, MARGO DENICE (O D)
Entity Type:Individual
Prefix:DR
First Name:MARGO
Middle Name:DENICE
Last Name:BOLER
Suffix:
Gender:F
Credentials:O D
Other - Prefix:
Other - First Name:MARGO
Other - Middle Name:DENICE
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:7950 CRAFT GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-6608
Mailing Address - Country:US
Mailing Address - Phone:662-893-3950
Mailing Address - Fax:662-893-3950
Practice Address - Street 1:7950 CRAFT GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-6608
Practice Address - Country:US
Practice Address - Phone:662-893-3950
Practice Address - Fax:662-893-3950
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS665152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS410000258Medicare ID - Type Unspecified