Provider Demographics
NPI:1548245392
Name:GILMORE, ROGER ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALAN
Last Name:GILMORE
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 1:3521 LIMBAUGH LN
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8789
Mailing Address - Country:US
Mailing Address - Phone:850-995-4798
Mailing Address - Fax:850-995-5776
Practice Address - Street 1:3521 LIMBAUGH LN
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-8789
Practice Address - Country:US
Practice Address - Phone:850-995-4798
Practice Address - Fax:850-995-5776
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2008-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 86621207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I42849Medicare UPIN
FLU5601ZMedicare ID - Type Unspecified
FLP00438169Medicare PIN