Provider Demographics
NPI:1891791265
Name:GILLIAM, RICHARD LEONARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEONARD
Last Name:GILLIAM
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 4451
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93921-4451
Mailing Address - Country:US
Mailing Address - Phone:831-375-6325
Mailing Address - Fax:
Practice Address - Street 1:2440 FREMONT ST STE 102B
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-6850
Practice Address - Country:US
Practice Address - Phone:831-646-3190
Practice Address - Fax:831-646-3195
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC66372Medicare UPIN