MEDICARE: MICHAEL P GILLILAND O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3605	OH

General Provider Information

NPI Number	:	1528038825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL P GILLILAND O.D.

Provider Business Mailing Address
First Line	:	15933 CLAYTON RD STE 201
Second Line	:
City	:	BALLWIN
State	:	MO
Zip	:	63011-2172
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-527-0766

Provider Business Practice Location Address
First Line	:	105 GREAT SOUTHERN BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43207-4001
Country	:	US
Telephone Number	:	614-491-3435
Fax Number	:	614-491-1699

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	10/04/2016

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