Provider Demographics
NPI:1851646061
Name:GILMAN, IAN
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:
Last Name:GILMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 SIMPSON DR
Mailing Address - Street 2:
Mailing Address - City:OLD BETHPAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11804-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42 SIMPSON DR
Practice Address - Street 2:
Practice Address - City:OLD BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11804-1220
Practice Address - Country:US
Practice Address - Phone:516-319-5706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY975864001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist