Provider Demographics
NPI:1891780094
Name:GILLESPIE, LAURIE H (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:H
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3888 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2417
Mailing Address - Country:US
Mailing Address - Phone:478-477-4044
Mailing Address - Fax:478-477-7076
Practice Address - Street 1:3888 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2417
Practice Address - Country:US
Practice Address - Phone:478-477-4044
Practice Address - Fax:478-477-7076
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.35484208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH62811Medicare UPIN