Provider Demographics
NPI:1891709630
Name:GILLES, JERRY N (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:N
Last Name:GILLES
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 1:1600 S. ANDREWS AVENUE
Mailing Address - Street 2:SUITE 323 WEST WING
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316
Mailing Address - Country:US
Mailing Address - Phone:954-355-5110
Mailing Address - Fax:954-355-4919
Practice Address - Street 1:300 SE 17TH STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316
Practice Address - Country:US
Practice Address - Phone:954-468-3080
Practice Address - Fax:954-468-3082
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71247207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2505274-00Medicaid
FL2505274-00Medicaid
FLG36999Medicare UPIN