Provider Demographics
NPI:1053492744
Name:MARK A GILLISPIE O D INC
Entity Type:Organization
Organization Name:MARK A GILLISPIE O D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GILLISPIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-347-6636
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004740Medicaid
CAGSD004740Medicaid
CA0286940001Medicare NSC