Provider Demographics
NPI:1467621185
Name:MARK A GILLISPIE O D INC
Entity Type:Organization
Organization Name:MARK A GILLISPIE O D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:GILLISPIE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:760-347-6636
Mailing Address - Street 1:82227 US HIGHWAY 111
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5667
Mailing Address - Country:US
Mailing Address - Phone:760-347-6636
Mailing Address - Fax:760-342-5987
Practice Address - Street 1:52565 HARRISON ST.
Practice Address - Street 2:SUITE 105
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236
Practice Address - Country:US
Practice Address - Phone:760-398-1500
Practice Address - Fax:760-398-8474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8413T152W00000X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD004740Medicaid
CAGSD004740Medicaid