=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568650331
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GORDON R. BOYD O.D.,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2007
-----------------------------------------------------
Last Update Date | 04/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1485 S. GRANT AVE SUITE A
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-362-3209
-----------------------------------------------------
Fax | 765-364-9233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1485 S. GRANT AVE SUITE A
-----------------------------------------------------
City | CRAWFORDSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47933-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-362-3209
-----------------------------------------------------
Fax | 765-364-9233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OPTOMETRIST
-----------------------------------------------------
Name | DR. GORDON R. BOYD
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 765-362-3209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 0474130001
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------