Provider Demographics
NPI:1114917317
Name:BLANKS, GILBERT C (OD)
Entity Type:Individual
Prefix:
First Name:GILBERT
Middle Name:C
Last Name:BLANKS
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 1:1015 LAURENCE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-2964
Mailing Address - Country:US
Mailing Address - Phone:517-787-0364
Mailing Address - Fax:517-787-2272
Practice Address - Street 1:1015 LAURENCE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-2964
Practice Address - Country:US
Practice Address - Phone:517-787-0364
Practice Address - Fax:517-787-2272
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003044152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU25899Medicare UPIN
MI3913940001Medicare NSC
MI3913940002Medicare NSC
MI0N16630Medicare PIN