Provider Demographics
NPI:1619975596
Name:GAYLORD, JOHN FREEMAN III (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:FREEMAN
Last Name:GAYLORD
Suffix:III
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 1:1970 ROANOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6404
Mailing Address - Country:US
Mailing Address - Phone:540-982-2463
Mailing Address - Fax:540-855-3406
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-982-2463
Practice Address - Fax:540-855-3406
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044349207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831141597OtherNPI GROUP
VA5831580Medicaid
VA5831580Medicaid
VAD95223Medicare UPIN