Provider Demographics
NPI:1134113277
Name:GILLETT, RICHARD CLARK (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CLARK
Last Name:GILLETT
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:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-571-1120
Mailing Address - Fax:706-571-1603
Practice Address - Street 1:1800 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-1513
Practice Address - Country:US
Practice Address - Phone:706-571-1120
Practice Address - Fax:706-571-1603
Is Sole Proprietor?:No
Enumeration Date:2005-09-05
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52324760 001OtherBCBS
GA000459258EMedicaid
080154745OtherRR MEDICARE
08CBCRHMedicare PIN
GA52324760 001OtherBCBS