Provider Demographics
NPI:1790734721
Name:GILLERAN, JASON P (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:P
Last Name:GILLERAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:31157 WOODWARD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0926
Mailing Address - Country:US
Mailing Address - Phone:248-336-0123
Mailing Address - Fax:248-336-3190
Practice Address - Street 1:31157 WOODWARD AVENUE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-0926
Practice Address - Country:US
Practice Address - Phone:248-336-0123
Practice Address - Fax:248-336-3190
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301096814208800000X
OH35086508208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I11607Medicare UPIN