Provider Demographics
NPI:1801661335
Name:GILLENWATER, JOSEPH (LDO)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:GILLENWATER
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 PRIVATE DRIVE 288
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-7900
Mailing Address - Country:US
Mailing Address - Phone:740-894-4749
Mailing Address - Fax:740-894-4827
Practice Address - Street 1:432 PRIVATE DRIVE 288
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680-7900
Practice Address - Country:US
Practice Address - Phone:740-894-4749
Practice Address - Fax:740-894-4827
Is Sole Proprietor?:No
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.007408-SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician