Provider Demographics
NPI:1336238492
Name:BOLLIG, DAVID L
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:BOLLIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 N 8TH
Mailing Address - Street 2:
Mailing Address - City:WAKEENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 N 14TH ST
Practice Address - Street 2:
Practice Address - City:WAKEENEY
Practice Address - State:KS
Practice Address - Zip Code:67672-3000
Practice Address - Country:US
Practice Address - Phone:785-743-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0421431208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS105875OtherBCBS - WFCC
KS105876OtherBCBS - EFCC
KS105876OtherBCBS - EFCC
045960Medicare ID - Type Unspecified