Provider Demographics
NPI:1720078397
Name:BOYD, MIRIAM S (OD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:S
Last Name:BOYD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 DUBOIS ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1048
Mailing Address - Country:US
Mailing Address - Phone:812-882-8500
Mailing Address - Fax:812-882-7785
Practice Address - Street 1:609 DUBOIS ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1048
Practice Address - Country:US
Practice Address - Phone:812-882-8500
Practice Address - Fax:812-882-7785
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001378152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000101141OtherANTHEM
IN954010Medicare PIN
T69304Medicare UPIN
0476020001Medicare NSC