Provider Demographics
NPI:1881649135
Name:GUILBERT, MICHAEL J (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:GUILBERT
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 1:88 CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:DEADWOOD
Mailing Address - State:SD
Mailing Address - Zip Code:57732-1303
Mailing Address - Country:US
Mailing Address - Phone:605-578-1761
Mailing Address - Fax:605-578-1121
Practice Address - Street 1:88 CHARLES ST
Practice Address - Street 2:
Practice Address - City:DEADWOOD
Practice Address - State:SD
Practice Address - Zip Code:57732-1303
Practice Address - Country:US
Practice Address - Phone:605-578-1761
Practice Address - Fax:605-578-1121
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9200452Medicaid
SD0745020001Medicare NSC
SDS102191Medicare PIN
SDT66605Medicare UPIN