Healthcare Provider Details

I. General information

NPI: 1720083199
Provider Name (Legal Business Name): CHARLES RICK GILLIAM O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date: 03/17/2006
Reactivation Date: 03/23/2006

III. Provider practice location address

6425 OLD PLANK RD STE E
HIGH POINT NC
27265-3277
US

IV. Provider business mailing address

PO BOX 4370
ARCHDALE NC
27263-4370
US

V. Phone/Fax

Practice location:
  • Phone: 336-886-7500
  • Fax: 336-886-7505
Mailing address:
  • Phone: 336-434-4033
  • Fax: 336-434-4035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1083
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: