Provider Demographics
NPI:1740275619
Name:GILLETT, ROBERT DONAT (OD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:DONAT
Last Name:GILLETT
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 1:418 W PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-3321
Mailing Address - Country:US
Mailing Address - Phone:559-784-4063
Mailing Address - Fax:559-784-2069
Practice Address - Street 1:418 W PUTNAM AVE
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-3321
Practice Address - Country:US
Practice Address - Phone:559-784-4063
Practice Address - Fax:559-784-2069
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6035TPL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0060350Medicaid
CAT10210Medicare UPIN
CASD0060350Medicaid
CA3969430001Medicare NSC