Provider Demographics
NPI:1164493979
Name:BODRIE, GREGORY TAYLOR (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:TAYLOR
Last Name:BODRIE
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:PO BOX 532
Mailing Address - Street 2:66 PLEASANT ST
Mailing Address - City:SAGAMORE
Mailing Address - State:MA
Mailing Address - Zip Code:02561-0532
Mailing Address - Country:US
Mailing Address - Phone:508-888-2020
Mailing Address - Fax:508-888-4423
Practice Address - Street 1:66 PLEASANT ST.
Practice Address - Street 2:
Practice Address - City:SAGAMORE
Practice Address - State:MA
Practice Address - Zip Code:02561-0532
Practice Address - Country:US
Practice Address - Phone:508-888-2020
Practice Address - Fax:508-888-4423
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAOD 2646 TPA152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA79402030OtherDET EMPLOYER ID
MAW15268OtherBLUE CROSS BLUE SHIELD
MA0332003Medicaid
MD710362OtherTUFTS HEALTH CARE HMO
MA171458Medicare PIN
MD710362OtherTUFTS HEALTH CARE HMO
MA79402030OtherDET EMPLOYER ID
MA0332003Medicaid