Provider Demographics
NPI:1790772200
Name:GILBREATH, MARILYN K (OD)
Entity Type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:K
Last Name:GILBREATH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-4316
Mailing Address - Country:US
Mailing Address - Phone:707-462-7040
Mailing Address - Fax:707-462-7089
Practice Address - Street 1:102 SCOTT ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-4316
Practice Address - Country:US
Practice Address - Phone:707-462-7040
Practice Address - Fax:707-462-7089
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7472T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0074720Medicaid
CAU21593Medicare UPIN
1790772200Medicare NSC