Provider Demographics
NPI:1811231525
Name:GILLIAM, FRED (HAS)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 WINONA TRL
Mailing Address - Street 2:
Mailing Address - City:DE LEON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32130-3613
Mailing Address - Country:US
Mailing Address - Phone:386-717-1621
Mailing Address - Fax:
Practice Address - Street 1:742 N VOLUSIA AVE
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-4857
Practice Address - Country:US
Practice Address - Phone:386-561-9496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4847174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist