Provider Demographics
NPI:1376529370
Name:GILLER, JERALD (MD)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:
Last Name:GILLER
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 1:60 MAPLE RD
Mailing Address - Street 2:STE 1
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2917
Mailing Address - Country:US
Mailing Address - Phone:716-626-5250
Mailing Address - Fax:716-626-5316
Practice Address - Street 1:60 MAPLE RD
Practice Address - Street 2:STE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2917
Practice Address - Country:US
Practice Address - Phone:716-626-5250
Practice Address - Fax:716-626-5316
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY096757207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2301493OtherINDEPENDENT HEALTH
NY00010063701OtherUNIVERA
NY00645616Medicaid
NY152308BTOtherPREFERRED CARE
NY5330097OtherAERNA
NY000505237001OtherBLUE CROSS OF WNY
NY00010063701OtherUNIVERA
NY152308BTOtherPREFERRED CARE