Provider Demographics
NPI:1770876021
Name:GILLENWATER, CHRISTINA B (MD)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:B
Last Name:GILLENWATER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 SKIDMORE LANE
Mailing Address - Street 2:
Mailing Address - City:SUTTON
Mailing Address - State:WV
Mailing Address - Zip Code:26601
Mailing Address - Country:US
Mailing Address - Phone:304-765-4400
Mailing Address - Fax:304-765-0354
Practice Address - Street 1:273 SKIDMORE LN
Practice Address - Street 2:
Practice Address - City:SUTTON
Practice Address - State:WV
Practice Address - Zip Code:26601-9272
Practice Address - Country:US
Practice Address - Phone:304-765-4400
Practice Address - Fax:304-765-0354
Is Sole Proprietor?:No
Enumeration Date:2011-05-19
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25672207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810027479Medicaid
WV1770876021Medicaid