Provider Demographics
NPI:1780667808
Name:GILL, LAWRENCE G III (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:G
Last Name:GILL
Suffix:III
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 1:1333 W. 5TH ST, STE 110
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2752
Mailing Address - Country:US
Mailing Address - Phone:307-672-2522
Mailing Address - Fax:307-672-3732
Practice Address - Street 1:1333 W 5TH ST, STE 210
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2752
Practice Address - Country:US
Practice Address - Phone:307-672-2522
Practice Address - Fax:307-672-3732
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3578A174400000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT97253Medicaid
WY110391100Medicaid
WY3578AOtherSTATE LICENSE NUMBER
WYAG1163687OtherDEA NUMBER
WY306050Medicare ID - Type Unspecified
WY110391100Medicaid