Provider Demographics
NPI:1275536633
Name:GILLMAN, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:GILLMAN
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 1:1120 W. LA VETA AVENUE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4246
Mailing Address - Country:US
Mailing Address - Phone:657-210-4096
Mailing Address - Fax:657-210-4233
Practice Address - Street 1:1120 W. LA VETA AVENUE
Practice Address - Street 2:SUITE 300
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4246
Practice Address - Country:US
Practice Address - Phone:657-210-4096
Practice Address - Fax:657-210-4233
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2015-10-14
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
CAG84341207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG76305Medicare UPIN