Provider Demographics
NPI:1669464582
Name:BOOZER, R BRYAN (OD)
Entity Type:Individual
Prefix:DR
First Name:R
Middle Name:BRYAN
Last Name:BOOZER
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 1:1000 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-4934
Mailing Address - Country:US
Mailing Address - Phone:256-739-4000
Mailing Address - Fax:256-734-1390
Practice Address - Street 1:1000 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-4934
Practice Address - Country:US
Practice Address - Phone:256-739-4000
Practice Address - Fax:256-734-1390
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS541TA016152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009911832Medicaid
AL515-44928OtherBC BS AL
ALT69136Medicare UPIN
AL0533600001Medicare NSC
AL515-44928OtherBC BS AL
AL510G700043Medicare PIN