Provider Demographics
NPI:1013008614
Name:BODILY, GREGORY N (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:N
Last Name:BODILY
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 1:610 AMERICANA BLVD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6731
Mailing Address - Country:US
Mailing Address - Phone:208-344-2020
Mailing Address - Fax:208-344-2371
Practice Address - Street 1:610 AMERICANA BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6731
Practice Address - Country:US
Practice Address - Phone:208-344-2020
Practice Address - Fax:208-344-2371
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP1013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1593538Medicare ID - Type Unspecified
IDU81868Medicare UPIN