Provider Demographics
NPI:1134301666
Name:BOARDSEN, DANNY R (OD PC)
Entity Type:Individual
Prefix:DR
First Name:DANNY
Middle Name:R
Last Name:BOARDSEN
Suffix:
Gender:M
Credentials:OD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-0400
Mailing Address - Country:US
Mailing Address - Phone:660-263-3737
Mailing Address - Fax:660-263-2375
Practice Address - Street 1:541 W REED ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-1509
Practice Address - Country:US
Practice Address - Phone:660-263-3737
Practice Address - Fax:660-263-2375
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02681152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0763840001Medicare NSC