Provider Demographics
NPI:1699767632
Name:BOLTZ, KENNETH DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DAVID
Last Name:BOLTZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5775 PERIMETER DR
Mailing Address - Street 2:STE 160
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3257
Mailing Address - Country:US
Mailing Address - Phone:614-763-5775
Mailing Address - Fax:614-675-3338
Practice Address - Street 1:5775 PERIMETER DR
Practice Address - Street 2:STE 160
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3257
Practice Address - Country:US
Practice Address - Phone:614-763-5775
Practice Address - Fax:614-675-3338
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3782152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHU20621Medicare UPIN
0521990001Medicare ID - Type UnspecifiedDURABLE GOODS