Provider Demographics
NPI:1851397236
Name:GILLEN, GARY L (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
Last Name:GILLEN
Suffix:
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:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-0749
Mailing Address - Country:US
Mailing Address - Phone:802-851-8619
Mailing Address - Fax:802-851-8716
Practice Address - Street 1:609 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-8652
Practice Address - Country:US
Practice Address - Phone:802-888-5639
Practice Address - Fax:802-888-6040
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042.0014151207Q00000X, 207Q00000X
OH35036140207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1033707Medicaid
OHH335790Medicare PIN
OHG10428475Medicare PIN
OH2056644Medicaid