Provider Demographics
NPI:1619954542
Name:GILLETT, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:GILLETT
Suffix:
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 1:201 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2403
Mailing Address - Country:US
Mailing Address - Phone:605-336-0635
Mailing Address - Fax:605-271-0543
Practice Address - Street 1:201 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2403
Practice Address - Country:US
Practice Address - Phone:605-336-0635
Practice Address - Fax:605-271-0543
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43656208800000X
SD5878208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0749101Medicaid
SDP00337027OtherRAILROAD MEDICARE
SD7500490Medicaid
MN165167600Medicaid
SD7500490Medicaid
SD101079Medicare PIN
IA0749101Medicaid