Provider Demographics
NPI:1184622441
Name:GILLILAND, BRUCE DEVIN (OD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:DEVIN
Last Name:GILLILAND
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 1:715 CALLAHAN DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-1302
Mailing Address - Country:US
Mailing Address - Phone:865-687-1232
Mailing Address - Fax:865-687-8256
Practice Address - Street 1:715 CALLAHAN DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37912-1302
Practice Address - Country:US
Practice Address - Phone:865-687-1232
Practice Address - Fax:865-687-8256
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1593152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4102823OtherBLUE CROSS BLUE SHILED
VA010168864Medicaid
TN3941143Medicaid
KY77620342Medicaid
TNP00317714OtherRAILROAD MEDICARE
TN3941143Medicare PIN
TNU65336Medicare UPIN