Provider Demographics
NPI:1033203757
Name:BOYLE, ROBERT BRUCE (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BRUCE
Last Name:BOYLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2757 S SENECA ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-2862
Mailing Address - Country:US
Mailing Address - Phone:316-260-6280
Mailing Address - Fax:316-665-6806
Practice Address - Street 1:2757 S SENECA ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-2862
Practice Address - Country:US
Practice Address - Phone:316-260-6280
Practice Address - Fax:316-665-6806
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1473-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS545740OtherCOVENTRY
KS1558670760OtherBC/BS
KS5062OtherPPK
KS100363120EMedicaid
KS3239530OtherCIGNA
KS27-3461950OtherFEDERAL TAX ID
KSKA1927001Medicare PIN
KS6487690001Medicare NSC
KS1558670760Medicare NSC
KS27-3461950OtherFEDERAL TAX ID
KS1558670760OtherBC/BS