Provider Demographics
NPI:1811003122
Name:GILLESPIE, DOUGLAS BURTON JR (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:BURTON
Last Name:GILLESPIE
Suffix:JR
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 1:2010 OHIO BLVD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47803-2122
Mailing Address - Country:US
Mailing Address - Phone:812-234-1938
Mailing Address - Fax:812-238-7837
Practice Address - Street 1:2010 OHIO BLVD
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47803-2122
Practice Address - Country:US
Practice Address - Phone:812-234-1938
Practice Address - Fax:812-238-7837
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029184A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4062053OtherAETNA ASSIGNED
000000089600OtherANTHEM
351904269178OtherCARESOURCE MEDICAID
0182827OtherUS DEPT OF LABOR
111276OtherHEALTHLINK
01393OtherCIGNA
D70851Medicare UPIN
4062053OtherAETNA ASSIGNED
IN192770DDMedicare PIN