Provider Demographics
NPI:1487640546
Name:GILLMAN, MARTIN B SR (DC)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:B
Last Name:GILLMAN
Suffix:SR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8046 KEW GARDENS RD
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-1154
Mailing Address - Country:US
Mailing Address - Phone:918-261-1000
Mailing Address - Fax:718-261-0336
Practice Address - Street 1:8046 KEW GARDENS RD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-1154
Practice Address - Country:US
Practice Address - Phone:918-261-1000
Practice Address - Fax:718-261-0336
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007375111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01811930Medicaid
U55520Medicare UPIN
02646TMedicare ID - Type Unspecified