Provider Demographics
NPI:1013945542
Name:GILLIS, BRUCE S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:S
Last Name:GILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11801 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1114
Mailing Address - Country:US
Mailing Address - Phone:310-268-1001
Mailing Address - Fax:310-268-1015
Practice Address - Street 1:11801 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1114
Practice Address - Country:US
Practice Address - Phone:310-268-1001
Practice Address - Fax:310-268-1015
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30367207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine