Provider Demographics
NPI:1720083199
Name:GILLIAM, CHARLES RICK (OD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICK
Last Name:GILLIAM
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 1:311 TRINDALE RD
Mailing Address - Street 2:STE D
Mailing Address - City:ARCHDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27263-2771
Mailing Address - Country:US
Mailing Address - Phone:336-434-4033
Mailing Address - Fax:336-434-4035
Practice Address - Street 1:311 TRINDALE RD
Practice Address - Street 2:STE D
Practice Address - City:ARCHDALE
Practice Address - State:NC
Practice Address - Zip Code:27263-2771
Practice Address - Country:US
Practice Address - Phone:336-434-4033
Practice Address - Fax:336-434-4035
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
NC1083152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909318Medicaid
NC09318OtherBCBSNC
NC246404CMedicare ID - Type Unspecified
NC8909318Medicaid
NC246404BMedicare ID - Type Unspecified
NC246404DMedicare UPIN