Provider Demographics
NPI:1730122276
Name:GILLUM, MICHAEL D (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:GILLUM
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:PO BOX 421
Mailing Address - Street 2:STE 200
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:509-474-2072
Mailing Address - Fax:
Practice Address - Street 1:624 E FRONT AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-2139
Practice Address - Country:US
Practice Address - Phone:509-626-9904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025477207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB11699Medicare PIN