Healthcare Provider Details

I. General information

NPI: 1275725897
Provider Name (Legal Business Name): NATHAN THOMAS GILMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35410 DEL REY
DANA POINT CA
92624-1814
US

IV. Provider business mailing address

1 HOAG DR
NEWPORT BEACH CA
92663-4162
US

V. Phone/Fax

Practice location:
  • Phone: 801-330-9242
  • Fax:
Mailing address:
  • Phone: 801-330-9242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberA126324
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: