Provider Demographics
NPI:1689667792
Name:GILLIS, DOUGLAS TERRY (DPM)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:TERRY
Last Name:GILLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 S WALNUT ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1425
Mailing Address - Country:US
Mailing Address - Phone:505-525-3980
Mailing Address - Fax:505-526-8529
Practice Address - Street 1:780 S WALNUT ST
Practice Address - Street 2:SUITE 3
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1425
Practice Address - Country:US
Practice Address - Phone:505-525-3980
Practice Address - Fax:505-526-8529
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM196213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0469220001OtherDMERC
NM88001A00ZOtherTRICARE WPS
NM52993Medicaid
NM16042OtherPRESBYTERIAN
NMNM005364OtherBC BS
NM16042OtherPRESBYTERIAN