Provider Demographics
NPI:1659354785
Name:GILLIAM, PAUL EDWIN JR (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWIN
Last Name:GILLIAM
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6310
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88006-6310
Mailing Address - Country:US
Mailing Address - Phone:575-556-6400
Mailing Address - Fax:575-556-6405
Practice Address - Street 1:2530 S TELSHOR BLVD
Practice Address - Street 2:STE 207
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4951
Practice Address - Country:US
Practice Address - Phone:575-556-6400
Practice Address - Fax:575-556-6405
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM97-247208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10827331Medicaid
NMP00905172OtherRR MEDICARE
NMP00905172OtherRR MEDICARE
NMNMA100365Medicare PIN