Provider Demographics
NPI:1679649297
Name:GILLMAN, KELVIN D (MD)
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:D
Last Name:GILLMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 NORTH MAIN STREET
Mailing Address - Street 2:STE #7
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904
Mailing Address - Country:US
Mailing Address - Phone:401-383-6776
Mailing Address - Fax:401-383-7213
Practice Address - Street 1:845 NORTH MAIN STREET
Practice Address - Street 2:STE #7
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904
Practice Address - Country:US
Practice Address - Phone:401-383-6776
Practice Address - Fax:401-383-7213
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI8918208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7004961Medicaid