Provider Demographics
NPI:1205831245
Name:GILLIES, DOUGLAS E (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:E
Last Name:GILLIES
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 1:1180 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3190
Mailing Address - Country:US
Mailing Address - Phone:734-243-5300
Mailing Address - Fax:734-243-9956
Practice Address - Street 1:1180 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3190
Practice Address - Country:US
Practice Address - Phone:734-243-5300
Practice Address - Fax:734-243-9956
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3071T456152W00000X
MI4901002418152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0261729Medicaid
MI410049894OtherMEDICARE RAILROAD
MI944352709Medicaid
OH410049893OtherMEDICARE RAILROAD
OH410049893OtherMEDICARE RAILROAD
MI944352709Medicaid
OH0261729Medicaid
OH9310791Medicare PIN
MI0N55410Medicare PIN
OH0408202Medicare PIN
OH9310794Medicare PIN
MI0N14190Medicare PIN