Healthcare Provider Details

I. General information

NPI: 1285769133
Provider Name (Legal Business Name): TIMOTHY H. MCGILLEN O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

279 W 80TH PL
MERRILLVILLE IN
46410-5491
US

IV. Provider business mailing address

9795 CROSSPOINT BLVD STE 100
INDIANAPOLIS IN
46256-3354
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-2180
  • Fax: 219-738-2847
Mailing address:
  • Phone: 317-254-6480
  • Fax: 317-259-8609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001839B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: