Provider Demographics
NPI:1902045446
Name:DUANE A GILLAM
Entity Type:Organization
Organization Name:DUANE A GILLAM
Other - Org Name:LAFAYETTE VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GILLAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-448-2711
Mailing Address - Street 1:638 S EARL AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3264
Mailing Address - Country:US
Mailing Address - Phone:765-448-2711
Mailing Address - Fax:765-448-2995
Practice Address - Street 1:638 S EARL AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3264
Practice Address - Country:US
Practice Address - Phone:765-448-2711
Practice Address - Fax:765-448-2995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-06
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001683B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100230920Medicaid
IN100230920Medicaid
INT-35045Medicare UPIN
IN0869830001Medicare NSC