Healthcare Provider Details

I. General information

NPI: 1992712616
Provider Name (Legal Business Name): VIVEK S GILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 04/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9723 SIERRA VISTA RD UNIT A
PHELAN CA
92371-8271
US

IV. Provider business mailing address

9723 SIERRA VISTA RD UNIT A
PHELAN CA
92371-8271
US

V. Phone/Fax

Practice location:
  • Phone: 760-868-1990
  • Fax: 760-868-1201
Mailing address:
  • Phone: 760-868-1990
  • Fax: 760-868-1201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA610540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: