Provider Demographics
NPI:1669713384
Name:WL GILMER, MD, PA
Entity type:Organization
Organization Name:WL GILMER, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:GILMER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:386-256-1212
Mailing Address - Street 1:5111 S RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-5170
Mailing Address - Country:US
Mailing Address - Phone:386-256-1212
Mailing Address - Fax:
Practice Address - Street 1:5111 S RIDGEWOOD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-5170
Practice Address - Country:US
Practice Address - Phone:386-256-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-05
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008424200Medicaid