Provider Demographics
NPI:1851315212
Name:BOLENBAKER, JASON ALLAN (OD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:ALLAN
Last Name:BOLENBAKER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8175 S VIRGINIA ST # B900
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-8922
Mailing Address - Country:US
Mailing Address - Phone:775-827-1100
Mailing Address - Fax:
Practice Address - Street 1:8175 S VIRGINIA ST # B900
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-8922
Practice Address - Country:US
Practice Address - Phone:775-827-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV100916Medicare UPIN