Healthcare Provider Details

I. General information

NPI: 1427052216
Provider Name (Legal Business Name): GORDON R BOYD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 S GRANT AVE STE A
CRAWFORDSVILLE IN
47933-3329
US

IV. Provider business mailing address

1485 S GRANT AVE STE A
CRAWFORDSVILLE IN
47933-3329
US

V. Phone/Fax

Practice location:
  • Phone: 765-362-3209
  • Fax: 765-364-9233
Mailing address:
  • Phone: 765-362-3209
  • Fax: 765-364-9233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2070
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: