Provider Demographics
NPI:1548243439
Name:GILDEA, JON R (DO)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:R
Last Name:GILDEA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT CH 17767
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60055-0001
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:2946 STARLIGHT DRIVE
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803
Practice Address - Country:US
Practice Address - Phone:406-240-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014660207P00000X, 207PE0004X
MT10620207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4614956Medicaid
MI4615292Medicaid
MI4617359Medicaid
JG014660OtherBLUE CROSS BLUE SHIELD
P00158334OtherRAILROAD MEDICARE
I05821Medicare UPIN
MI4617359Medicaid