Provider Demographics
NPI:1043391899
Name:GILLISPIE, MARK A (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:GILLISPIE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:82227 US HIGHWAY 111
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5667
Mailing Address - Country:US
Mailing Address - Phone:760-347-6636
Mailing Address - Fax:760-342-5987
Practice Address - Street 1:82227 US HIGHWAY 111
Practice Address - Street 2:SUITE B-2
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5667
Practice Address - Country:US
Practice Address - Phone:760-347-6636
Practice Address - Fax:760-342-5987
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8413T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0084130Medicaid
0286940001Medicare NSC
CASD0084130Medicare PIN
CASD0084130Medicaid