Provider Demographics
NPI:1013914225
Name:GILLIN, DANA E (OD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:E
Last Name:GILLIN
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 1:112 N EVANS ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1578
Mailing Address - Country:US
Mailing Address - Phone:517-424-1010
Mailing Address - Fax:517-592-5048
Practice Address - Street 1:112 N EVANS ST
Practice Address - Street 2:SUITE 2
Practice Address - City:TECUMSEH
Practice Address - State:MI
Practice Address - Zip Code:49286-1578
Practice Address - Country:US
Practice Address - Phone:517-424-1010
Practice Address - Fax:517-592-5048
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2014-07-28
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
MI4901003791152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU50619Medicare UPIN
MIP21380001Medicare PIN