Provider Demographics
NPI:1376509190
Name:GILLILAND, MARTIN E (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:E
Last Name:GILLILAND
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 1:315 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4013
Mailing Address - Country:US
Mailing Address - Phone:409-384-3430
Mailing Address - Fax:409-383-0571
Practice Address - Street 1:315 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4013
Practice Address - Country:US
Practice Address - Phone:409-384-3430
Practice Address - Fax:409-383-0571
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133051602Medicaid
TX133051602Medicaid
TX85X800Medicare ID - Type Unspecified