Provider Demographics
NPI:1073603718
Name:BOARDMAN, AVERY B (OD)
Entity Type:Individual
Prefix:DR
First Name:AVERY
Middle Name:B
Last Name:BOARDMAN
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 1:889 CRAFTMASTER ROAD
Mailing Address - Street 2:PO BOX 331
Mailing Address - City:WYSOX
Mailing Address - State:PA
Mailing Address - Zip Code:18854-0000
Mailing Address - Country:US
Mailing Address - Phone:570-265-3668
Mailing Address - Fax:570-265-8936
Practice Address - Street 1:889 CRAFTMASTER ROAD
Practice Address - Street 2:
Practice Address - City:WYSOX
Practice Address - State:PA
Practice Address - Zip Code:18854-0000
Practice Address - Country:US
Practice Address - Phone:570-265-3668
Practice Address - Fax:570-265-8936
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000896152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012690190004Medicaid
PAU24495Medicare UPIN
PA690610Medicare PIN