Provider Demographics
NPI:1326174558
Name:GILLIAM, PHILLIP LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LEE
Last Name:GILLIAM
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 1:2103 CAMELOT CIR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2932
Mailing Address - Country:US
Mailing Address - Phone:423-854-9210
Mailing Address - Fax:423-854-9210
Practice Address - Street 1:114 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-3339
Practice Address - Country:US
Practice Address - Phone:423-543-3421
Practice Address - Fax:423-543-7099
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1262152W00000X
TN1262152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN910711OtherEYEMED INSURANCE PROVIDER
TNQ019840Medicaid
TN910711OtherEYEMED INSURANCE PROVIDER
TNQ019840Medicaid