Provider Demographics
NPI:1497847123
Name:GILL, MICHAEL DENNIS (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:GILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1025 E OCEAN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436
Mailing Address - Country:US
Mailing Address - Phone:805-735-7621
Mailing Address - Fax:805-736-5378
Practice Address - Street 1:1025 E OCEAN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436
Practice Address - Country:US
Practice Address - Phone:805-735-7621
Practice Address - Fax:805-736-5378
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG54515207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG54515OtherLICENSE
A93306Medicare UPIN
CAG54515OtherLICENSE