Provider Demographics
NPI:1598781429
Name:GILLIAM, JOHN ANDERSON II (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDERSON
Last Name:GILLIAM
Suffix:II
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 1:607 WELCH ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381
Mailing Address - Country:US
Mailing Address - Phone:508-873-3636
Mailing Address - Fax:503-873-1457
Practice Address - Street 1:607 WELCH ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381
Practice Address - Country:US
Practice Address - Phone:508-873-3636
Practice Address - Fax:503-873-1457
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR151306Medicaid
OR151306Medicaid
OR102174Medicare ID - Type Unspecified