Provider Demographics
NPI:1356312755
Name:GILLEN, JOHN B III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:GILLEN
Suffix:III
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 1:435 SOUTH BURNETT ROAD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2717
Mailing Address - Country:US
Mailing Address - Phone:937-325-8796
Mailing Address - Fax:937-325-3640
Practice Address - Street 1:435 SOUTH BURNETT ROAD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2717
Practice Address - Country:US
Practice Address - Phone:937-325-8796
Practice Address - Fax:937-325-3640
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-4962-G207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000009482OtherANTHEM PROVIDER NUMBER
OH040006587OtherRAILROAD MEDICARE PROVIDE
OH0931684Medicaid
OH1000182OtherUNITED HEALTH CARE PROVID
OH4321313OtherAETNA PROVIDER NUMBER
OH1000182OtherUNITED HEALTH CARE PROVID
OH0931684Medicaid