Provider Demographics
NPI:1528116217
Name:PAINTER, BOBBY G (OD)
Entity type:Individual
Prefix:
First Name:BOBBY
Middle Name:G
Last Name:PAINTER
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 1:3280 N BUTLER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2360
Mailing Address - Country:US
Mailing Address - Phone:505-325-2015
Mailing Address - Fax:505-327-9877
Practice Address - Street 1:3280 N BUTLER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2360
Practice Address - Country:US
Practice Address - Phone:505-325-2015
Practice Address - Fax:505-327-9877
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM297152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP2280Medicaid
NM344532701Medicare ID - Type UnspecifiedMEDICARE
NM$$$$$$$$$Medicare PIN
NMU12139Medicare UPIN