MEDICARE: GILLIAN WESTON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207N00000X	Dermatology Physician	067343	CT

General Provider Information

NPI Number	:	1063861268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GILLIAN WESTON MD

Provider Business Mailing Address
First Line	:	21 SOUTH RD
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06032-2482
Country	:	US
Telephone Number	:	860-679-4600
Fax Number	:	860-679-7534

Provider Business Practice Location Address
First Line	:	21 S RD DERMATOLOGY
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06030-1807
Country	:	US
Telephone Number	:	860-679-4600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	09/28/2022

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