Provider Demographics
NPI:1952458580
Name:BOLLENBACHER, JEFFERY A (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:A
Last Name:BOLLENBACHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3402
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-0402
Mailing Address - Country:US
Mailing Address - Phone:812-234-4243
Mailing Address - Fax:812-478-3663
Practice Address - Street 1:3903 S 7TH ST STE 1A
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-5710
Practice Address - Country:US
Practice Address - Phone:812-237-1411
Practice Address - Fax:812-237-9242
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001578207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE85659Medicare UPIN