Provider Demographics
NPI:1730122383
Name:GILLIAM, ROBERT MILTON (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MILTON
Last Name:GILLIAM
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 1:4406 N LAURENT ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-2742
Mailing Address - Country:US
Mailing Address - Phone:361-578-0107
Mailing Address - Fax:361-578-1320
Practice Address - Street 1:4406 N LAURENT ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-2742
Practice Address - Country:US
Practice Address - Phone:361-578-0107
Practice Address - Fax:361-578-1320
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2574207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098147402Medicaid
TX0880170001OtherCIGNA GOVERNMENT SUPPLIER NUMBER
TX098147402Medicaid