Provider Demographics
NPI:1578640215
Name:BOLLINGER, MELISSA KAY (OD)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:KAY
Last Name:BOLLINGER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:KAY
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1007 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5034
Mailing Address - Country:US
Mailing Address - Phone:614-353-4874
Mailing Address - Fax:
Practice Address - Street 1:300 N MILWAUKEE AVE STE L
Practice Address - Street 2:
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-8563
Practice Address - Country:US
Practice Address - Phone:847-356-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011293152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200857700Medicaid
IN200857700Medicaid