Provider Demographics
NPI:1851392666
Name:GILLETTE, THEODORE N (OD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:N
Last Name:GILLETTE
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 1:11650 131ST ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-4740
Mailing Address - Country:US
Mailing Address - Phone:727-489-0500
Mailing Address - Fax:727-489-0508
Practice Address - Street 1:11650 131ST ST
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-4740
Practice Address - Country:US
Practice Address - Phone:727-489-0500
Practice Address - Fax:727-489-0508
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-02
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1574152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620866500Medicaid
FL20105WMedicare ID - Type UnspecifiedOAF GROUP K0738A
FLT77500Medicare UPIN
FL620866500Medicaid