1467621185 NPI number — MARK A GILLISPIE O D INC

Table of content: (NPI 1467621185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467621185 NPI number — MARK A GILLISPIE O D INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK A GILLISPIE O D INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467621185
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
82227 US HIGHWAY 111
Provider Second Line Business Mailing Address:
SUITE B-2
Provider Business Mailing Address City Name:
INDIO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92201-5667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-347-6636
Provider Business Mailing Address Fax Number:
760-342-5987

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
52565 HARRISON ST.
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
COACHELLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-398-1500
Provider Business Practice Location Address Fax Number:
760-398-8474
Provider Enumeration Date:
02/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GILLISPIE
Authorized Official First Name:
MARK
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER / DOCTOR
Authorized Official Telephone Number:
760-347-6636

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  8413T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X , with the licence number: 8413T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GSD004740 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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