Healthcare Provider Details

I. General information

NPI: 1235130337
Provider Name (Legal Business Name): ROBERT BRUCE GILLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL, CAMP PENDLETON BLDG H100, SANTA MARGARITA ROAD, ATTN: CODE CS-PA
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

1224 VALENTINE LN
FALLBROOK CA
92028-9246
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-1400
  • Fax:
Mailing address:
  • Phone: 760-728-6242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number41758-020
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberGFE69629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: