Provider Demographics
NPI:1649221870
Name:GILLETTE, WARREN JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:
Last Name:GILLETTE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WARREN
Other - Middle Name:
Other - Last Name:GILLETTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1253 COLLEGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-8713
Mailing Address - Country:US
Mailing Address - Phone:302-677-0000
Mailing Address - Fax:
Practice Address - Street 1:1253 COLLEGE PARK DR
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-8713
Practice Address - Country:US
Practice Address - Phone:302-677-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20124208D00000X, 174400000X
PAMD463045207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE90056Medicare UPIN