Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | ODP1013 | ID |
NPI | 1013008614 |
---|---|
Provider Name | Dr. Gregory N Bodily |
First Address | Boise, ID 83702-6731 |
Second Address | Boise, ID 83702-6731 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U81868 | (02) | ID |