Provider Demographics
NPI:1295728012
Name:GAUTHIER, GEORGE W III (DC)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:GAUTHIER
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 DANADA SQ E
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-8484
Mailing Address - Country:US
Mailing Address - Phone:630-682-8682
Mailing Address - Fax:630-681-8366
Practice Address - Street 1:57 DANADA SQ E
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-8484
Practice Address - Country:US
Practice Address - Phone:630-682-8682
Practice Address - Fax:630-681-8366
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2206151OtherBCBS PROVIDER #
IL2206151OtherBCBS PROVIDER #