Provider Demographics
NPI:1548587025
Name:GILLETTE, CARL RUSSELL (DO)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:RUSSELL
Last Name:GILLETTE
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 1:15448 FIDDLESTICKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4022
Mailing Address - Country:US
Mailing Address - Phone:239-225-1517
Mailing Address - Fax:239-225-7311
Practice Address - Street 1:15448 FIDDLESTICKS BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4022
Practice Address - Country:US
Practice Address - Phone:239-225-1517
Practice Address - Fax:239-225-7311
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.001344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine