Provider Demographics
NPI:1700845948
Name:GILLEN, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:GILLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:513-585-5505
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:7850 CAMARGO RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45243-2652
Practice Address - Country:US
Practice Address - Phone:513-561-5655
Practice Address - Fax:513-561-2319
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-025979207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0117224Medicaid
OH180031749OtherRAILROAD MEDICARE
OH0117224Medicaid
OH0129294Medicare PIN
OH0129293Medicare PIN
OHC00614Medicare UPIN
OH0129298Medicare PIN
OH0129292Medicare PIN
OH0129295Medicare PIN