Basic Information
| Provider Information | |||||||||
| NPI: | 1285769133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGILLEN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9795 CROSSPOINT BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172546480 | ||||||||
| FaxNumber: | 3172598609 | ||||||||
| Practice Location | |||||||||
| Address1: | 279 W 80TH PL | ||||||||
| Address2: | |||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464105491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197382180 | ||||||||
| FaxNumber: | 2197382847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2007 | ||||||||
| LastUpdateDate: | 09/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001839B | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201037950A | 05 | IN | MEDICAID |