Provider Demographics
NPI:1396925533
Name:GALLATIN, CHAD R (OD)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:R
Last Name:GALLATIN
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:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48139-0767
Mailing Address - Country:US
Mailing Address - Phone:810-231-5800
Mailing Address - Fax:810-231-6422
Practice Address - Street 1:10105 VETERANS MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITMORE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48189-9767
Practice Address - Country:US
Practice Address - Phone:810-231-5800
Practice Address - Fax:810-231-6422
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003817152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI4985Medicare PIN
MIU78389Medicare UPIN
MIP00455040Medicare PIN