Provider Demographics
NPI:1649235532
Name:GILLILAND, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:GILLILAND
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 1:8813 S 71ST EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5056
Mailing Address - Country:US
Mailing Address - Phone:918-809-0712
Mailing Address - Fax:918-524-6055
Practice Address - Street 1:8813 S 71ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5056
Practice Address - Country:US
Practice Address - Phone:918-809-0712
Practice Address - Fax:918-524-6055
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10961207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
E15961Medicare UPIN