Provider Demographics
NPI:1558413807
Name:GAILLARD, THADDEUS B JR (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:B
Last Name:GAILLARD
Suffix:JR
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 381257
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1257
Mailing Address - Country:US
Mailing Address - Phone:662-349-4377
Mailing Address - Fax:662-349-4378
Practice Address - Street 1:401 SOUTHCREST CIRCLE
Practice Address - Street 2:SUITE 102
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-349-4377
Practice Address - Fax:662-349-4378
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15990207VG0400X
MS11279207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3018336Medicaid
TN3018336Medicaid
TN3018336Medicare ID - Type Unspecified