Provider Demographics
NPI:1417012808
Name:GILLIS-HARRY, DEINSO (MD)
Entity Type:Individual
Prefix:
First Name:DEINSO
Middle Name:
Last Name:GILLIS-HARRY
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 1:510 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:315-591-9442
Mailing Address - Fax:315-591-9448
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:315-591-9442
Practice Address - Fax:315-591-9448
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19496071146D00000X
NY194607-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant