Provider Demographics
NPI:1770916058
Name:BOLAY, ELISE R
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:R
Last Name:BOLAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 COFFEY DR
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-5807
Mailing Address - Country:US
Mailing Address - Phone:405-250-6815
Mailing Address - Fax:
Practice Address - Street 1:833 E 33RD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5407
Practice Address - Country:US
Practice Address - Phone:405-216-5508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2765152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist