Provider Demographics
NPI:1003877085
Name:GILLIAM, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15029 N THOMPSON PEAK PARKWAY
Mailing Address - Street 2:STE B-111 PMB 438
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-2223
Mailing Address - Country:US
Mailing Address - Phone:405-590-8861
Mailing Address - Fax:800-960-4547
Practice Address - Street 1:20172 E STAGECOACH TRL
Practice Address - Street 2:
Practice Address - City:MAYER
Practice Address - State:AZ
Practice Address - Zip Code:86333-2357
Practice Address - Country:US
Practice Address - Phone:800-288-6206
Practice Address - Fax:800-960-4547
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16226207P00000X
AZ41469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100044450BMedicaid
AZ600874OtherAHCCCS (ARIZONA MEDICAID) ID
AZZ144938OtherMEDICARE PTAN
OK100044450AMedicaid
OK244301604Medicare PIN
OK930046552Medicare PIN
OK100044450AMedicaid
AZ600874OtherAHCCCS (ARIZONA MEDICAID) ID
OK100044450BMedicaid
OK247226117Medicare PIN