Provider Demographics
NPI:1801858451
Name:GILMORE, MICHAEL JUAN (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JUAN
Last Name:GILMORE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5471 DR. MARTIN LUTHER KING DR.
Mailing Address - Street 2:STE A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-4265
Mailing Address - Country:US
Mailing Address - Phone:314-367-5820
Mailing Address - Fax:314-367-6326
Practice Address - Street 1:5471 DR. MARTIN LUTHER KING DR.
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-4265
Practice Address - Country:US
Practice Address - Phone:314-367-5820
Practice Address - Fax:314-367-6326
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA66073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A66073Medicaid
CAA66073Medicare ID - Type Unspecified
CA00A66073Medicaid