Provider Demographics
NPI:1790889137
Name:STILLER, GABRIELE (MD)
Entity Type:Individual
Prefix:DR
First Name:GABRIELE
Middle Name:
Last Name:STILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5472 W PINE LODGE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8614
Mailing Address - Country:US
Mailing Address - Phone:575-627-7463
Mailing Address - Fax:505-407-1783
Practice Address - Street 1:5472 W PINE LODGE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-8614
Practice Address - Country:US
Practice Address - Phone:575-627-7463
Practice Address - Fax:505-407-1783
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM97-380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB8576Medicaid
NMG73744Medicare UPIN