Provider Demographics
NPI:1992973986
Name:GREGORY T BODRIE OD
Entity type:Organization
Organization Name:GREGORY T BODRIE OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:BODRIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:508-888-2020
Mailing Address - Street 1:PO BOX 532
Mailing Address - Street 2:66 PLEASANT STREET
Mailing Address - City:SAGAMORE
Mailing Address - State:MA
Mailing Address - Zip Code:02561-0532
Mailing Address - Country:US
Mailing Address - Phone:508-888-2020
Mailing Address - Fax:508-888-4423
Practice Address - Street 1:66 PLEASANT ST.
Practice Address - Street 2:
Practice Address - City:SAGAMORE
Practice Address - State:MA
Practice Address - Zip Code:02561-0532
Practice Address - Country:US
Practice Address - Phone:508-888-2020
Practice Address - Fax:508-888-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2646332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0332003Medicaid
MAW15268OtherBLUE CROSS / BLUE SHIELD
MA0332003Medicaid
MA4688780001Medicare NSC