Provider Demographics
NPI:1336219773
Name:BODIFORD EYE INSTITUTE, PA
Entity Type:Organization
Organization Name:BODIFORD EYE INSTITUTE, PA
Other - Org Name:BODIFORD EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BODIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-649-7018
Mailing Address - Street 1:9001 JENNY LIND RD
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8629
Mailing Address - Country:US
Mailing Address - Phone:479-649-7018
Mailing Address - Fax:479-649-7024
Practice Address - Street 1:9001 JENNY LIND RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8629
Practice Address - Country:US
Practice Address - Phone:479-649-7018
Practice Address - Fax:479-649-7024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-1402207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B988OtherBLUE CROSS
AR1163920001OtherDMERC
OK100728040AMedicaid
OK180029680OtherRR MEDICARE
AR180034141OtherRAILROAD MEDICARE
OK432291569-001OtherBLUE CROSS
OK=========Medicare ID - Type Unspecified
OK100728040AMedicaid