Provider Demographics
NPI:1386986545
Name:BOLYARD, BENNETT ADAM (DO)
Entity type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:ADAM
Last Name:BOLYARD
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 1:3231 S NATIONAL AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7304
Mailing Address - Country:US
Mailing Address - Phone:417-888-5658
Mailing Address - Fax:417-841-0104
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-888-5658
Practice Address - Fax:417-841-0104
Is Sole Proprietor?:No
Enumeration Date:2013-03-25
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH34.011878207R00000X
MO2016012954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH437610Medicare PIN