Provider Demographics
NPI:1205928223
Name:GILMORE, TEDRA (MD)
Entity type:Individual
Prefix:
First Name:TEDRA
Middle Name:
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7141 SECURITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1800
Mailing Address - Country:US
Mailing Address - Phone:800-777-7904
Mailing Address - Fax:386-258-6882
Practice Address - Street 1:105 MCALPINE LN
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-4637
Practice Address - Country:US
Practice Address - Phone:910-504-8530
Practice Address - Fax:910-291-7180
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 98980207V00000X
NC2022-02131207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL278400900Medicaid