Provider Demographics
NPI:1447262076
Name:GILL, PAUL A (OD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:GILL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4835 LONG CANON PL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:321 E WAYNE ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-2713
Practice Address - Country:US
Practice Address - Phone:260-424-5656
Practice Address - Fax:260-424-4511
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002653A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2904281Medicaid
IN000000112751OtherANTHEM
IN200241660AMedicaid
IN410040576Medicare PIN
IN000000112751OtherANTHEM
OH2904281Medicaid
IN176220GMedicare PIN
INU75940Medicare UPIN
IN905780OMedicare PIN
IN209800NMedicare PIN
IN252850BMedicare PIN