Provider Demographics
NPI:1609984665
Name:BOLOS, HOWARD (OD)
Entity type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:
Last Name:BOLOS
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 1:113 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-7832
Mailing Address - Country:US
Mailing Address - Phone:321-636-4422
Mailing Address - Fax:321-632-9254
Practice Address - Street 1:113 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-7832
Practice Address - Country:US
Practice Address - Phone:321-636-4422
Practice Address - Fax:321-632-9254
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 001719152WC0802X
FLOPC1719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078230100Medicaid
FL078230100Medicaid
FLT93889Medicare UPIN