Provider Demographics
NPI:1811186059
Name:GUILLORY, MIA J (OD)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:J
Last Name:GUILLORY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1124 E WEISGARBER RD STE 104
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2686
Mailing Address - Country:US
Mailing Address - Phone:865-584-0905
Mailing Address - Fax:865-392-5536
Practice Address - Street 1:10841 HARDIN VALLEY RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932
Practice Address - Country:US
Practice Address - Phone:658-584-0905
Practice Address - Fax:865-584-3892
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA1543152W00000X
IL046010059152W00000X
TNPENDING152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist