Healthcare Provider Details

I. General information

NPI: 1235789355
Provider Name (Legal Business Name): THOMAS GILLIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 W CIVIC CENTER DR
SANTA ANA CA
92701-4006
US

IV. Provider business mailing address

615 W CIVIC CENTER DR STE 200
SANTA ANA CA
92701-4052
US

V. Phone/Fax

Practice location:
  • Phone: 714-795-3444
  • Fax: 714-795-3443
Mailing address:
  • Phone: 714-795-3444
  • Fax: 714-795-3443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: