Provider Demographics
NPI:1912112632
Name:GAILLARD, IAN TREVOR (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:TREVOR
Last Name:GAILLARD
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 2650
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2650
Mailing Address - Country:US
Mailing Address - Phone:870-541-7211
Mailing Address - Fax:870-541-4297
Practice Address - Street 1:1609 W 40TH AVE STE 401
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6365
Practice Address - Country:US
Practice Address - Phone:870-541-7201
Practice Address - Fax:870-541-7202
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN49633207RG0100X
ARE17339207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology