Provider Demographics
NPI:1568650331
Name:GORDON R. BOYD O.D.,P.C.
Entity Type:Organization
Organization Name:GORDON R. BOYD O.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-362-3209
Mailing Address - Street 1:1485 S. GRANT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-3329
Mailing Address - Country:US
Mailing Address - Phone:765-362-3209
Mailing Address - Fax:765-364-9233
Practice Address - Street 1:1485 S. GRANT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3329
Practice Address - Country:US
Practice Address - Phone:765-362-3209
Practice Address - Fax:765-364-9233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0474130001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU25862OtherVSP
IN556050Medicare PIN
INU25862OtherVSP
IN0474130001Medicare NSC