Provider Demographics
NPI:1427105865
Name:GILMORE, LEE JOSEPH (OD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:JOSEPH
Last Name:GILMORE
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 1:4201 W DIVISION ST STE 90
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4546
Mailing Address - Country:US
Mailing Address - Phone:320-259-1131
Mailing Address - Fax:320-259-9394
Practice Address - Street 1:4201 W DIVISION ST STE 90
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4546
Practice Address - Country:US
Practice Address - Phone:320-259-1131
Practice Address - Fax:320-259-9394
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU98524Medicare UPIN
MN410002115Medicare ID - Type Unspecified