=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205831245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOUGLAS E GILLIES O.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2005
-----------------------------------------------------
Last Update Date | 02/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1180 N MONROE ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-243-5300
-----------------------------------------------------
Fax | 734-243-9956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1180 N MONROE ST
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-3190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-243-5300
-----------------------------------------------------
Fax | 734-243-9956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 3071T456
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4901002418
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------