Provider Demographics
NPI:1407024367
Name:PAUL S. GILLUM, MD, PC
Entity Type:Organization
Organization Name:PAUL S. GILLUM, MD, PC
Other - Org Name:OKLAHOMA DERMATOLOGY INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-360-9588
Mailing Address - Street 1:2413 PALMER CIR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-6301
Mailing Address - Country:US
Mailing Address - Phone:405-360-9588
Mailing Address - Fax:405-321-5348
Practice Address - Street 1:2413 PALMER CIR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-6301
Practice Address - Country:US
Practice Address - Phone:405-360-9588
Practice Address - Fax:405-321-5348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18048207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG20264Medicare UPIN