Provider Demographics
NPI:1528038825
Name:GILLILAND, MICHAEL P (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:GILLILAND
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 1:15933 CLAYTON RD STE 201
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:105 GREAT SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4001
Practice Address - Country:US
Practice Address - Phone:614-491-3435
Practice Address - Fax:614-491-1699
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3605152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0524509Medicare PIN
OH3605Medicare UPIN
1184130001Medicare NSC