Provider Demographics
NPI:1780678847
Name:GILFILLAN, KENNETH R (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:GILFILLAN
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 1:8826 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-8596
Mailing Address - Country:US
Mailing Address - Phone:937-725-6696
Mailing Address - Fax:937-848-6101
Practice Address - Street 1:3951 W FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:BELLBROOK
Practice Address - State:OH
Practice Address - Zip Code:45305-1834
Practice Address - Country:US
Practice Address - Phone:937-848-6601
Practice Address - Fax:937-848-6101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3028152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT46260Medicare UPIN
OH9284051Medicare ID - Type Unspecified