Provider Demographics
NPI:1942983705
Name:GILLIAM, TRENTON DEVONTE'
Entity Type:Individual
Prefix:
First Name:TRENTON
Middle Name:DEVONTE'
Last Name:GILLIAM
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 1:130 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3343
Mailing Address - Country:US
Mailing Address - Phone:901-849-5952
Mailing Address - Fax:
Practice Address - Street 1:TROUT AVE
Practice Address - Street 2:BLDG 159
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-694-2876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman