Provider Demographics
NPI:1255960357
Name:GILLIAM, NICHOLAS (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4131
Practice Address - Country:US
Practice Address - Phone:800-229-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS210662084P0800X
OH34.0169632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry