Provider Demographics
NPI:1730687260
Name:BOYD, GABRIELLE GANDY (OD)
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:GANDY
Last Name:BOYD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 E BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-6000
Mailing Address - Country:US
Mailing Address - Phone:318-798-4539
Mailing Address - Fax:318-798-4601
Practice Address - Street 1:471 ASHLEY RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7229
Practice Address - Country:US
Practice Address - Phone:318-795-4770
Practice Address - Fax:318-795-4775
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1866801AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2476815Medicaid