Provider Demographics
NPI:1942277280
Name:GILLESPIE, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4630 VILLAGE SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-7502
Mailing Address - Country:US
Mailing Address - Phone:270-442-1671
Mailing Address - Fax:270-442-7307
Practice Address - Street 1:4630 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-7502
Practice Address - Country:US
Practice Address - Phone:270-442-1671
Practice Address - Fax:270-442-7307
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME148468207W00000X
KY24107207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000044961OtherANTHEM BCBS
IL0470581032Medicaid
180011413OtherRAILROAD MEDICARE
KY64241078Medicaid
610706763OtherTRICARE
KY7100053130Medicaid
0584203Medicare PIN