=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164493979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY TAYLOR BODRIE O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2006
-----------------------------------------------------
Last Update Date | 01/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 PLEASANT ST.
-----------------------------------------------------
City | SAGAMORE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02561-0532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-888-2020
-----------------------------------------------------
Fax | 508-888-4423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 532 66 PLEASANT ST
-----------------------------------------------------
City | SAGAMORE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02561-0532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-888-2020
-----------------------------------------------------
Fax | 508-888-4423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number | OD 2646 TPA
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------