Provider Demographics
NPI:1992823462
Name:BOLDUS, NEIL ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:ALAN
Last Name:BOLDUS
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 1:14 S PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2628
Mailing Address - Country:US
Mailing Address - Phone:312-432-0080
Mailing Address - Fax:312-432-0586
Practice Address - Street 1:14 S PEORIA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2628
Practice Address - Country:US
Practice Address - Phone:312-432-0080
Practice Address - Fax:312-432-0586
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009186152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU78635Medicare UPIN