Healthcare Provider Details

I. General information

NPI: 1831178334
Provider Name (Legal Business Name): LOUIS GEORGE GILLERAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ROSECRANS ST SWMI, BLDG 500 NAVAL SUBMARINE BASE SAN DIEGO
SAN DIEGO CA
92106-4408
US

IV. Provider business mailing address

2725 E BAINBRIDGE RD
SAN DIEGO CA
92106-6070
US

V. Phone/Fax

Practice location:
  • Phone: 619-553-0097
  • Fax:
Mailing address:
  • Phone: 619-795-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberC51060
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: