Provider Demographics
NPI:1043301195
Name:GILSON, MICHAEL KENNETH (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KENNETH
Last Name:GILSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 GILMAN DR
Mailing Address - Street 2:MC0736
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92093-0736
Mailing Address - Country:US
Mailing Address - Phone:858-822-0622
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR
Practice Address - Street 2:MC0736
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-0736
Practice Address - Country:US
Practice Address - Phone:858-822-0622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0047320207R00000X
CAG69466208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine