Provider Demographics
NPI:1619916657
Name:MILLESEN, GWENDOLYN J (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:J
Last Name:MILLESEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 UTAH PL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1458
Mailing Address - Country:US
Mailing Address - Phone:740-594-8770
Mailing Address - Fax:
Practice Address - Street 1:55 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2302
Practice Address - Country:US
Practice Address - Phone:740-592-9349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20341207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1054725OtherWV WORK COMP
WV3810001713Medicaid
OH2216364OtherOHIO MEDICAID
WV1054725OtherWV WORK COMP
OH2216364OtherOHIO MEDICAID