Provider Demographics
NPI:1437456498
Name:GILLILAND, MARK DOUGLAS (CSA)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:MR
Other - First Name:MARK
Other - Middle Name:DOUGLAS
Other - Last Name:GILLILAND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSA
Mailing Address - Street 1:484 N POST OAK LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-5911
Mailing Address - Country:US
Mailing Address - Phone:713-303-9714
Mailing Address - Fax:
Practice Address - Street 1:484 N POST OAK LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-5911
Practice Address - Country:US
Practice Address - Phone:713-303-9714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-27
Last Update Date:2011-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical