Provider Demographics
NPI:1245219633
Name:GILLETT, EDWARD ROGER (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ROGER
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 1:1636 72ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4600
Mailing Address - Country:US
Mailing Address - Phone:813-890-6215
Mailing Address - Fax:877-814-8601
Practice Address - Street 1:700 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4815
Practice Address - Country:US
Practice Address - Phone:727-893-6197
Practice Address - Fax:727-553-7340
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2008-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68481207QS0010X
FLME-68481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379349400Medicaid
E47197Medicare UPIN
27360ZMedicare ID - Type Unspecified