1811003122 NPI number — DOUGLAS BURTON GILLESPIE JR. M.D.

Table of content: DONAVAN M MAYBERRY (NPI 1578309787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811003122 NPI number — DOUGLAS BURTON GILLESPIE JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLESPIE
Provider First Name:
DOUGLAS
Provider Middle Name:
BURTON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
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:
1811003122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 OHIO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TERRE HAUTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47803-2122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-234-1938
Provider Business Mailing Address Fax Number:
812-238-7837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2010 OHIO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TERRE HAUTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47803-2122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-234-1938
Provider Business Practice Location Address Fax Number:
812-238-7837
Provider Enumeration Date:
08/21/2006

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: 207R00000X , with the licence number:  01029184A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4062053 . This is a "AETNA ASSIGNED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000089600 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 351904269178 . This is a "CARESOURCE MEDICAID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0182827 . This is a "US DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 111276 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01393 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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