Provider Demographics
NPI:1124195482
Name:GILLESS, JANICE W (MD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:W
Last Name:GILLESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 AIRPORT BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-2048
Mailing Address - Country:US
Mailing Address - Phone:650-240-8198
Mailing Address - Fax:
Practice Address - Street 1:901 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-4900
Practice Address - Country:US
Practice Address - Phone:650-652-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51007208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081920Medicaid
CAGR0081920Medicaid
CA943293486OtherPRACTICE TAX ID NUMBER