Provider Demographics
NPI:1154553097
Name:BOLLAR, TERESITA A
Entity type:Individual
Prefix:
First Name:TERESITA
Middle Name:A
Last Name:BOLLAR
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 1:19013 BISCAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2819
Mailing Address - Country:US
Mailing Address - Phone:305-935-5250
Mailing Address - Fax:
Practice Address - Street 1:19013 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-2819
Practice Address - Country:US
Practice Address - Phone:305-935-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4426152W00000X
FL4426152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001540300Medicaid