Provider Demographics
NPI:1285769133
Name:MCGILLEN, TIMOTHY H (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:H
Last Name:MCGILLEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9795 CROSSPOINT BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3354
Mailing Address - Country:US
Mailing Address - Phone:317-254-6480
Mailing Address - Fax:317-259-8609
Practice Address - Street 1:279 W 80TH PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5491
Practice Address - Country:US
Practice Address - Phone:219-738-2180
Practice Address - Fax:219-738-2847
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001839B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201037950AMedicaid
IN201037950AMedicaid
ININ1100001Medicare PIN
IN0457900001Medicare NSC
IN492760Medicare PIN