Healthcare Provider Details

I. General information

NPI: 1275536633
Provider Name (Legal Business Name): MICHAEL J. GILLMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/24/2006

III. Provider practice location address

1120 W. LA VETA AVENUE SUITE 300
ORANGE CA
92868-4246
US

IV. Provider business mailing address

1120 W. LA VETA AVENUE SUITE 300
ORANGE CA
92868-4246
US

V. Phone/Fax

Practice location:
  • Phone: 657-210-4096
  • Fax: 657-210-4233
Mailing address:
  • Phone: 657-210-4096
  • Fax: 657-210-4233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG84341
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberG84341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: