Provider Demographics
NPI:1346349909
Name:BOLD, MICHAEL SCOTT (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:BOLD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:5422 LA PALMA AVE
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1705
Mailing Address - Country:US
Mailing Address - Phone:714-995-1144
Mailing Address - Fax:714-995-7979
Practice Address - Street 1:2628 SAN MIGUEL DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-5437
Practice Address - Country:US
Practice Address - Phone:949-644-0165
Practice Address - Fax:949-644-7762
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CACOR905152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist