Provider Demographics
NPI:1962414078
Name:BOLAND, MICHAEL R (OD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BOLAND
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2661 RIVA RD STE 1030
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-7131
Mailing Address - Country:US
Mailing Address - Phone:410-571-8733
Mailing Address - Fax:410-571-6309
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:18411-1557
Practice Address - Country:US
Practice Address - Phone:570-587-5186
Practice Address - Fax:570-586-7973
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000077152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
49959OtherGEISINGER HEALTH PLAN
180033988OtherRAILROAD MEDICARE
PA001699824Medicaid
BO975359OtherHIGH MARK BLUE SHIELD
806719OtherFIRST PRIORITY HEALTH
506554OtherAETNA
180033988OtherRAILROAD MEDICARE
U71384Medicare UPIN