Provider Demographics
NPI:1750424073
Name:BOURDON, GREG DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:DAVID
Last Name:BOURDON
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 1:1183 TREETOP CT
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-6787
Mailing Address - Country:US
Mailing Address - Phone:419-868-8988
Mailing Address - Fax:
Practice Address - Street 1:5001 MONROE ST
Practice Address - Street 2:JCPENNEY OPTICAL
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3627
Practice Address - Country:US
Practice Address - Phone:419-474-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5198 T2102152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2373784Medicaid
OHU93639Medicare UPIN