Provider Demographics
NPI:1689647547
Name:GILL, VIJAY S (MD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY
Middle Name:S
Last Name:GILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2152 S VINEYARD
Mailing Address - Street 2:SUITE 119
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6871
Mailing Address - Country:US
Mailing Address - Phone:480-964-1702
Mailing Address - Fax:480-964-1737
Practice Address - Street 1:2152 S VINEYARD
Practice Address - Street 2:SUITE 119
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-6871
Practice Address - Country:US
Practice Address - Phone:480-964-1702
Practice Address - Fax:480-964-1737
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ22590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ354316Medicaid
AZ354316Medicaid
AZF89837Medicare UPIN