Provider Demographics
NPI:1780686527
Name:BOLLENBACHER, MICHAEL A (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:BOLLENBACHER
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 1:2525 ARAPAHOE AVE
Mailing Address - Street 2:SUITE E23
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-6720
Mailing Address - Country:US
Mailing Address - Phone:303-444-1405
Mailing Address - Fax:303-413-9421
Practice Address - Street 1:2525 ARAPAHOE AVE
Practice Address - Street 2:SUITE E23
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-6720
Practice Address - Country:US
Practice Address - Phone:303-444-1405
Practice Address - Fax:303-413-9421
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2008152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66232091Medicaid
CO66232091Medicaid
COCD4478Medicare ID - Type Unspecified