Healthcare Provider Details

I. General information

NPI: 1467621185
Provider Name (Legal Business Name): MARK A GILLISPIE O D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 06/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52565 HARRISON ST. SUITE 105
COACHELLA CA
92236
US

IV. Provider business mailing address

82227 US HIGHWAY 111 SUITE B-2
INDIO CA
92201-5667
US

V. Phone/Fax

Practice location:
  • Phone: 760-398-1500
  • Fax: 760-398-8474
Mailing address:
  • Phone: 760-347-6636
  • Fax: 760-342-5987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8413T
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number8413T
License Number StateCA

VIII. Authorized Official

Name: DR. MARK A GILLISPIE
Title or Position: OWNER / DOCTOR
Credential: O.D.
Phone: 760-347-6636