Provider Demographics
NPI:1598074353
Name:GILLETTE, NICKOLAS JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:JOHN
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1611 S BALTIMORE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-4536
Mailing Address - Country:US
Mailing Address - Phone:660-665-7575
Mailing Address - Fax:660-665-7576
Practice Address - Street 1:1611 S BALTIMORE ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-4536
Practice Address - Country:US
Practice Address - Phone:660-665-7575
Practice Address - Fax:660-665-7576
Is Sole Proprietor?:No
Enumeration Date:2010-09-28
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2010019755207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine