Provider Demographics
NPI:1497759765
Name:GILLIAM, OLIVER D (MD)
Entity Type:Individual
Prefix:DR
First Name:OLIVER
Middle Name:D
Last Name:GILLIAM
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 1:17501 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1589
Mailing Address - Country:US
Mailing Address - Phone:574-234-0049
Mailing Address - Fax:574-251-2861
Practice Address - Street 1:17501 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1589
Practice Address - Country:US
Practice Address - Phone:574-234-0049
Practice Address - Fax:574-251-2861
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01035882A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100090510Medicaid
IN2738533002OtherCIGNA
IN000000084427OtherANTHEM
IN4667992OtherAETNA
IN100010837OtherRAILROAD MEDICARE
INC24549Medicare UPIN
IN736980DMedicare PIN