=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568627305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOYD KELLY GUBLER OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2008
-----------------------------------------------------
Last Update Date | 06/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17961 S US HIGHWAY 441
-----------------------------------------------------
City | SUMMERFIELD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34491-8685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-889-8420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17961 S US HIGHWAY 441
-----------------------------------------------------
City | SUMMERFIELD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34491-8685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-889-8420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1101
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC6658
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------