Provider Demographics
NPI:1427052216
Name:BOYD, GORDON R (OD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:R
Last Name:BOYD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 S GRANT AVE
Mailing Address - Street 2:STE A
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-3329
Mailing Address - Country:US
Mailing Address - Phone:765-362-3209
Mailing Address - Fax:765-364-9233
Practice Address - Street 1:1485 S GRANT AVE
Practice Address - Street 2:STE A
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-3329
Practice Address - Country:US
Practice Address - Phone:765-362-3209
Practice Address - Fax:765-364-9233
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2070152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN35-2055953OtherEMPLOYER TAX ID
INDMERCOtherDURABLE MED. EQUIP. #
INU25862OtherVSP
IN410048352OtherPALMETTO GBA
IN0474130001OtherDMERC
INDMERCOtherDURABLE MED. EQUIP. #