Provider Demographics
NPI:1245224104
Name:GILLICK, ROY H (MD)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:H
Last Name:GILLICK
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 1:830 MASON RD
Mailing Address - Street 2:A4
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-3896
Mailing Address - Country:US
Mailing Address - Phone:281-392-2222
Mailing Address - Fax:281-392-4861
Practice Address - Street 1:830 MASON RD
Practice Address - Street 2:A4
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-3896
Practice Address - Country:US
Practice Address - Phone:281-392-2222
Practice Address - Fax:281-392-4861
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7950207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX897626Medicare PIN
TXB22984Medicare UPIN