Provider Demographics
NPI:1528035664
Name:GILLETTE, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GILLETTE
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:PO BOX 409036
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-9036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6500 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4309
Practice Address - Country:US
Practice Address - Phone:352-333-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0079320207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268694500Medicaid
FL37752OtherBCBS
FL37752OtherBCBS
FL37752WMedicare PIN
FL37752AMedicare ID - Type UnspecifiedMEDICARE