Provider Demographics
NPI:1629005822
Name:GILLESPIE, IAN G (MS)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:G
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 GARTH RD
Mailing Address - Street 2:STE Q
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-3947
Mailing Address - Country:US
Mailing Address - Phone:281-420-8033
Mailing Address - Fax:281-420-8057
Practice Address - Street 1:2800 GARTH RD
Practice Address - Street 2:STE Q
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-3947
Practice Address - Country:US
Practice Address - Phone:281-420-8033
Practice Address - Fax:281-420-8057
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51198237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145676603Medicaid
TX80221AMedicare ID - Type Unspecified
TXP20854Medicare UPIN