Provider Demographics
NPI:1447281761
Name:GILLAM, DUANE A (OD)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:A
Last Name:GILLAM
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 1:638 S EARL AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-3264
Mailing Address - Country:US
Mailing Address - Phone:765-448-2711
Mailing Address - Fax:765-448-2995
Practice Address - Street 1:638 S EARL AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-3264
Practice Address - Country:US
Practice Address - Phone:765-448-2711
Practice Address - Fax:765-448-2995
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001683B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INT35045Medicare UPIN
IN803990Medicare PIN
IN0869830001Medicare NSC