Provider Demographics
NPI:1578189346
Name:GILLON, MATTHEW (OD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GILLON
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 1:9429 W CALLE LEJOS
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-1125
Mailing Address - Country:US
Mailing Address - Phone:571-332-7423
Mailing Address - Fax:
Practice Address - Street 1:85 W COMBS RD STE 108
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-9107
Practice Address - Country:US
Practice Address - Phone:602-239-4286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002438152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist