Provider Demographics
NPI:1972850113
Name:BOLANOS, MELODY (OD)
Entity Type:Individual
Prefix:DR
First Name:MELODY
Middle Name:
Last Name:BOLANOS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19101 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5332
Mailing Address - Country:US
Mailing Address - Phone:954-608-2080
Mailing Address - Fax:
Practice Address - Street 1:17782 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3923
Practice Address - Country:US
Practice Address - Phone:954-438-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4694152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist