Healthcare Provider Details

I. General information

NPI: 1124195482
Provider Name (Legal Business Name): JANICE W GILLESS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 CAMPUS DR
DALY CITY CA
94015-4900
US

IV. Provider business mailing address

577 AIRPORT BLVD SUITE 300
BURLINGAME CA
94010-2048
US

V. Phone/Fax

Practice location:
  • Phone: 650-652-8720
  • Fax:
Mailing address:
  • Phone: 650-240-8198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG51007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: