Provider Demographics
NPI:1457412637
Name:GAILLARD, WENDELL ELLIOTT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:ELLIOTT
Last Name:GAILLARD
Suffix:JR
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 1:727 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901
Mailing Address - Country:US
Mailing Address - Phone:706-660-6500
Mailing Address - Fax:706-660-6456
Practice Address - Street 1:727 CENTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:706-660-6500
Practice Address - Fax:706-660-6456
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054146208600000X
AL7516207Q00000X
GA54149207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA90-0137146OtherBLUE CROSS
GA104594099AMedicaid
GA02BBGMZMedicare PIN
AL051507588Medicare PIN
GA90-0137146OtherBLUE CROSS