Provider Demographics
NPI:1922098540
Name:GILLOGLY, ALAN YOUNG (OD)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:YOUNG
Last Name:GILLOGLY
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 1:3014 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43204-2652
Mailing Address - Country:US
Mailing Address - Phone:614-274-1451
Mailing Address - Fax:614-274-2908
Practice Address - Street 1:3014 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-2652
Practice Address - Country:US
Practice Address - Phone:614-274-1451
Practice Address - Fax:614-274-2908
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3736 T457152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0710243Medicaid
OH410003795OtherRAILROAD MEDICARE #
OH0710243Medicaid
OH0189160001Medicare NSC
OH0556781Medicare PIN