Provider Demographics
NPI:1073797858
Name:GILLIAM, KEVIN LOUIS II (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:LOUIS
Last Name:GILLIAM
Suffix:II
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 1:1313 PENN AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-3047
Mailing Address - Country:US
Mailing Address - Phone:612-543-2500
Mailing Address - Fax:
Practice Address - Street 1:1313 PENN AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411-3047
Practice Address - Country:US
Practice Address - Phone:612-543-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine