Provider Demographics
NPI:1912043738
Name:GILLESPIE, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:GILLESPIE
Suffix:
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-4260
Practice Address - Fax:682-885-2874
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL69102080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00U87ZOtherMEDICARE GROUP NUMBER
TX150220509OtherCSHCN GROUP NUMBER
TX161201203Medicaid
TX161201204OtherCSHCN NUMBER
TX140442852OtherMEDICAID GROUP NUMBER
TX161201206OtherCSHCN NUMBER
00257TOtherMEDICARE GROUP NUMBER
TX137345810OtherCSHCN GROUP NUMBER
TX161201205Medicaid
TX150220508OtherMEDICAID GROUP NUMBER
TX161201205Medicaid
TX8L14551Medicare PIN