Provider Demographics
NPI:1952316366
Name:GILLS, EDWARD LARRY (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:LARRY
Last Name:GILLS
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 1:612 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-4702
Mailing Address - Country:US
Mailing Address - Phone:479-785-2431
Mailing Address - Fax:479-494-7787
Practice Address - Street 1:1301 S E ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-4716
Practice Address - Country:US
Practice Address - Phone:479-785-2431
Practice Address - Fax:479-494-7787
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1830207Q00000X
ARARLIC#E-1830207Q00000X
TXTXLIC#J-8549207Q00000X
OKOKLIC#27469207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100166610CMedicaid
AR135306001Medicaid
OK100166610CMedicaid