Provider Demographics
NPI:1114922127
Name:GILL, LAWRENCE A (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:A
Last Name:GILL
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 1:3814 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2234
Mailing Address - Country:US
Mailing Address - Phone:614-871-2080
Mailing Address - Fax:614-871-1301
Practice Address - Street 1:3814 BROADWAY
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123
Practice Address - Country:US
Practice Address - Phone:614-871-2080
Practice Address - Fax:614-871-1301
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2908 T455152W00000X
OH2908/T455152WC0802X, 152WS0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH410011215OtherRAILROAD MEDICARE
OH410011215OtherRAILROAD MEDICARE
OHT46133Medicare UPIN
OH0560960001Medicare NSC