Provider Demographics
NPI:1578504726
Name:KINGMAN, GILSON JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:GILSON
Middle Name:JOHN
Last Name:KINGMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:2901 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-765-8620
Mailing Address - Fax:336-768-6236
Practice Address - Street 1:2901 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103
Practice Address - Country:US
Practice Address - Phone:336-765-8620
Practice Address - Fax:336-768-6236
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001205450207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCB0941OtherMECOST
P00024584OtherRAILROAD MEDICARE
NC49032OtherBCBS
NC8798OtherPARTNERS
NC8949032Medicaid
NC8798OtherPARTNERS
P00024584OtherRAILROAD MEDICARE