Provider Demographics
NPI:1720195571
Name:BOLLING, BRUCE RICHARD (MD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:RICHARD
Last Name:BOLLING
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4020
Mailing Address - Country:US
Mailing Address - Phone:336-659-9440
Mailing Address - Fax:336-659-9845
Practice Address - Street 1:3001 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4020
Practice Address - Country:US
Practice Address - Phone:336-659-9440
Practice Address - Fax:336-659-9845
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC592174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89127RYMedicaid
NC127RYOtherBCBS
NC2281805AMedicare ID - Type UnspecifiedMEDICARE
NC89127RYMedicaid