Provider Demographics
NPI:1053309229
Name:GILLOCK, CHARLES BUCKLEY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BUCKLEY
Last Name:GILLOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:BUCKLEY
Other - Last Name:GILLOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 GLOUCESTER RD
Practice Address - Street 2:
Practice Address - City:STUARTS DRAFT
Practice Address - State:VA
Practice Address - Zip Code:24477-3321
Practice Address - Country:US
Practice Address - Phone:540-337-3710
Practice Address - Fax:540-337-0930
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101047505208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007501188Medicaid
VA279040OtherBCBS ANTHEM
G25454Medicare UPIN
340012022Medicare PIN
340000457Medicare PIN