Provider Demographics
NPI:1225190242
Name:GILBERT, KENNETH GORDON JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:GORDON
Last Name:GILBERT
Suffix:JR
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 1:3202 B LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-5208
Mailing Address - Country:US
Mailing Address - Phone:217-356-4191
Mailing Address - Fax:877-350-5447
Practice Address - Street 1:3202 B LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-5208
Practice Address - Country:US
Practice Address - Phone:217-356-4191
Practice Address - Fax:877-350-5447
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360503672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036050367Medicaid
IL254211Medicare ID - Type Unspecified