1235135815 NPI number — LELAND T GILMORE DPM

Table of content: LELAND T GILMORE DPM (NPI 1235135815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235135815 NPI number — LELAND T GILMORE DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE
Provider First Name:
LELAND
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235135815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8101 HINSON FARM RD STE 301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALEXANDRIA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22306-3405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-560-3773
Provider Business Mailing Address Fax Number:
703-799-0050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8101 HINSON FARM RD STE 301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALEXANDRIA
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22306-3405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-560-3773
Provider Business Practice Location Address Fax Number:
703-799-0050
Provider Enumeration Date:
06/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  0103000826 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 290062 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 009302867 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480008618 . This is a "RAILROAD MEDICRE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: A729 0001 . This is a "CAREFIRST/BCBS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 010837200 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1699963157 . This is a "GROUP NPI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 105546001 . This is a "DME SUPPLIER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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