Healthcare Provider Details

I. General information

NPI: 1164493979
Provider Name (Legal Business Name): GREGORY TAYLOR BODRIE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 PLEASANT ST.
SAGAMORE MA
02561-0532
US

IV. Provider business mailing address

PO BOX 532 66 PLEASANT ST
SAGAMORE MA
02561-0532
US

V. Phone/Fax

Practice location:
  • Phone: 508-888-2020
  • Fax: 508-888-4423
Mailing address:
  • Phone: 508-888-2020
  • Fax: 508-888-4423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOD 2646 TPA
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: