Provider Demographics
NPI:1760062616
Name:GILLUM, ROGER DEAN
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DEAN
Last Name:GILLUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 SPRINGHILL DR
Mailing Address - Street 2:STE 200
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72117-2910
Mailing Address - Country:US
Mailing Address - Phone:501-259-4914
Mailing Address - Fax:501-534-4305
Practice Address - Street 1:3201 SPRINGHILL DR STE 300
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2909
Practice Address - Country:US
Practice Address - Phone:501-753-4132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program