Provider Demographics
NPI:1215049069
Name:BOLAND, STANLEY W (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:W
Last Name:BOLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MIFFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503
Mailing Address - Country:US
Mailing Address - Phone:570-342-3145
Mailing Address - Fax:570-344-1309
Practice Address - Street 1:503 S STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKS SUMMIT
Practice Address - State:PA
Practice Address - Zip Code:18411
Practice Address - Country:US
Practice Address - Phone:570-587-5186
Practice Address - Fax:570-586-7973
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028117L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
072551OtherFIRST PRIORTIY HEALTH
506554OtherAETNA
BO019514OtherHIGH MARK BLUE SHIELD
16915OtherGEISINGER HEALTH PLAN
072551OtherFIRST PRIORTIY HEALTH
PAB0019514Medicare ID - Type Unspecified