Provider Demographics
NPI:1629432745
Name:GILLETT, ETHAN (MD)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
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 1:1 CHILDRENS WAY # 653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:501-364-4082
Practice Address - Street 1:1 CHILDRENS WAY # 512-16
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-3500
Practice Address - Country:US
Practice Address - Phone:501-364-1874
Practice Address - Fax:501-364-3196
Is Sole Proprietor?:No
Enumeration Date:2016-04-06
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-12341208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics