Provider Demographics
NPI:1629170360
Name:GILLETTE, PHILLIP RANDALL
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:RANDALL
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EYEWORLD VISION
Other - Middle Name:
Other - Last Name:CENTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1088 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:SARALAND
Mailing Address - State:AL
Mailing Address - Zip Code:36571-3720
Mailing Address - Country:US
Mailing Address - Phone:251-675-3666
Mailing Address - Fax:251-675-9366
Practice Address - Street 1:1088 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:SARALAND
Practice Address - State:AL
Practice Address - Zip Code:36571-3720
Practice Address - Country:US
Practice Address - Phone:251-675-3666
Practice Address - Fax:251-675-9366
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51059805OtherBLUE CROSS