Provider Demographics
NPI:1578806451
Name:GILLUM, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:GILLUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 CHESHIRE BRIDGE RD NE APT 4204
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5733
Mailing Address - Country:US
Mailing Address - Phone:606-923-0381
Mailing Address - Fax:
Practice Address - Street 1:2124 CHESHIRE BRIDGE RD NE APT 4204
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-5733
Practice Address - Country:US
Practice Address - Phone:606-923-0381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant