Healthcare Provider Details

I. General information

NPI: 1164564530
Provider Name (Legal Business Name): NEIL BENNETT GAILMARD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 04/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 RIDGE RD
MUNSTER IN
46321-1610
US

IV. Provider business mailing address

630 RIDGE RD
MUNSTER IN
46321-1610
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-1738
  • Fax: 219-836-2822
Mailing address:
  • Phone: 219-836-1738
  • Fax: 219-836-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001742AB
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: