Healthcare Provider Details

I. General information

NPI: 1093039372
Provider Name (Legal Business Name): MICHAEL D. GILL MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2010
Last Update Date: 03/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 E. OCEAN AVE STE. A
LOMPOC CA
93436-7088
US

IV. Provider business mailing address

1025 E. OCEAN AVE, STE A
LOMPOC CA
93436-7088
US

V. Phone/Fax

Practice location:
  • Phone: 805-735-7621
  • Fax: 805-736-5378
Mailing address:
  • Phone: 805-735-7621
  • Fax: 805-736-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG54515
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierG54515
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerLICENSE#

VIII. Authorized Official

Name: MR. MICHAEL DENNIS GILL
Title or Position: MD, OWNER
Credential: MD
Phone: 805-735-7621