Provider Demographics
NPI:1598756579
Name:GILLETTE, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:GILLETTE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:831-454-4663
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC293282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC29328OtherPROFESSIONAL LICENSE #
CAZZZ91891ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CA00C293280Medicaid
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAC29328OtherPROFESSIONAL LICENSE #