Provider Demographics
NPI:1962627984
Name:MCVAY GILLAM, MARCENE R (MD)
Entity Type:Individual
Prefix:
First Name:MARCENE
Middle Name:R
Last Name:MCVAY GILLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARCENE
Other - Middle Name:RENEE
Other - Last Name:MCVAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:#1 CHILDREN'S WAY #653
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-1100
Mailing Address - Fax:
Practice Address - Street 1:6151 S YALE AVE STE 1305
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1907
Practice Address - Country:US
Practice Address - Phone:918-494-9450
Practice Address - Fax:918-494-9437
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-79332086S0120X
OK422642086S0120X
ARE-4933208600000X
TXP36502086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery