Provider Demographics
NPI:1265413769
Name:FILLMORE, GARY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:FILLMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9911 N NEVADA ST STE B
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99218-1298
Mailing Address - Country:US
Mailing Address - Phone:509-484-5710
Mailing Address - Fax:509-487-1000
Practice Address - Street 1:9911 N NEVADA ST STE B
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218
Practice Address - Country:US
Practice Address - Phone:509-484-5710
Practice Address - Fax:509-487-1000
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00049255207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00642793OtherRAILROAD MEDICARE
WAMD00049255OtherPHYSICIAN AND SURGEON LICENSE
WA0239190OtherDEPT OF LABOR AND INDUSTRIES
ID808422000Medicaid
WA8509440Medicaid
WA8949273OtherCRIME VICTIMS' COMPENSATION
WAG8874801OtherMEDICARE PTAN
WAG8874801OtherMEDICARE PTAN