Provider Demographics
NPI:1386027241
Name:GILLETTE, EMILY RENAE (OD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:RENAE
Last Name:GILLETTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:RENAE
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:220 MARCELL DR NE APT 2
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1375
Mailing Address - Country:US
Mailing Address - Phone:810-814-1266
Mailing Address - Fax:
Practice Address - Street 1:5100 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2049
Practice Address - Country:US
Practice Address - Phone:616-233-4403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004898152W00000X, 152WC0802X, 152WP0200X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision