Provider Demographics
NPI:1114931250
Name:GILES, GREGORY EDWARD SR (OD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:EDWARD
Last Name:GILES
Suffix:SR
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 1:8007 LA MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6434
Mailing Address - Country:US
Mailing Address - Phone:619-466-5665
Mailing Address - Fax:619-466-5688
Practice Address - Street 1:8007 LA MESA BLVD
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-6434
Practice Address - Country:US
Practice Address - Phone:619-466-5665
Practice Address - Fax:619-466-5688
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11362T152W00000X, 152WP0200X, 152WS0006X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0113620Medicaid
CAWOP11362AMedicare ID - Type Unspecified
CAU89204Medicare UPIN