Provider Demographics
NPI:1255488995
Name:GILLOCK, WILLIAM L JR (MPT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:L
Last Name:GILLOCK
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 HIGHWAY 99 N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-9649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1801 HIGHWAY 99 N
Practice Address - Street 2:SUITE 1
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-9649
Practice Address - Country:US
Practice Address - Phone:541-482-9051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4808225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR120607Medicare ID - Type Unspecified