Provider Demographics
NPI:1932288131
Name:MICHAEL J GUILBERT, OD, PC
Entity Type:Organization
Organization Name:MICHAEL J GUILBERT, OD, PC
Other - Org Name:DEADWOOD EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:605-578-1761
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD148152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9200452Medicaid
SD9200452Medicaid
SD0745020001Medicare NSC
SDS75003Medicare PIN