Provider Demographics
NPI:1609900547
Name:GILMORE, MYRIAM DAWIS (MD)
Entity Type:Individual
Prefix:
First Name:MYRIAM
Middle Name:DAWIS
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MYRIAM
Other - Middle Name:VILLAREAL
Other - Last Name:DAWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4425 BRANDT DR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8016
Mailing Address - Country:US
Mailing Address - Phone:918-458-5581
Mailing Address - Fax:
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3120
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN-6490208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD04567Medicare UPIN
OK8HAW44Medicare ID - Type UnspecifiedMEDICARE PROVIDER#- WWH