Provider Demographics
NPI:1346328911
Name:GILMORE, DAVID A (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:GILMORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:DAVID
Other - Middle Name:A
Other - Last Name:SUSSMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:510 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-2904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 S 4TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2904
Practice Address - Country:US
Practice Address - Phone:315-555-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001033171100000X
NYA204316207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02379335Medicaid
NY5903572OtherGHI PPO
NY000918142003OtherHEALTHNOW NY
NY204316-4 WOtherWORKER'S COMPENSATION
NY02379335Medicaid
NY02379335Medicaid