Provider Demographics
NPI:1114931250
Name:GILES, GREGORY EDWARD (OD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:EDWARD
Last Name:GILES
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 1:7863 LA MESA BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-6708
Mailing Address - Country:US
Mailing Address - Phone:619-399-2506
Mailing Address - Fax:619-399-2507
Practice Address - Street 1:7863 LA MESA BLVD STE 202
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-6708
Practice Address - Country:US
Practice Address - Phone:619-399-2506
Practice Address - Fax:619-399-2507
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11362T152WP0200X, 152WS0006X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0113620Medicaid
CAWOP11362AMedicare ID - Type Unspecified
CAU89204Medicare UPIN