Provider Demographics
NPI:1508855784
Name:KILGO, J DOUGLAS (OD)
Entity Type:Individual
Prefix:DR
First Name:J
Middle Name:DOUGLAS
Last Name:KILGO
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 1:1401 HAYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28791-2335
Mailing Address - Country:US
Mailing Address - Phone:828-693-5205
Mailing Address - Fax:828-693-0122
Practice Address - Street 1:1401 HAYWOOD RD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-2335
Practice Address - Country:US
Practice Address - Phone:828-693-5205
Practice Address - Fax:828-693-0122
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1052152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909487Medicaid
NC8909487Medicaid