Provider Demographics
NPI:1154390177
Name:GILLIS, MARK ROBERT (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:GILLIS
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 1:3021 CORRAL DR
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84040-7448
Mailing Address - Country:US
Mailing Address - Phone:801-444-2551
Mailing Address - Fax:
Practice Address - Street 1:1600 W ANTELOPE DR
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-807-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT50872591205207L00000X
ORMD176903207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4357Medicaid
UTD4357Medicaid