Provider Demographics
NPI:1487061925
Name:BERGELT, SOLITA JONES (OD)
Entity type:Individual
Prefix:DR
First Name:SOLITA
Middle Name:JONES
Last Name:BERGELT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SOLITA
Other - Middle Name:JONES
Other - Last Name:BERGELT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2672 DAVID H MCLEOD BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4042
Mailing Address - Country:US
Mailing Address - Phone:843-773-2758
Mailing Address - Fax:
Practice Address - Street 1:2672 DAVID H MCLEOD BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4042
Practice Address - Country:US
Practice Address - Phone:843-773-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1835152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist