Healthcare Provider Details

I. General information

NPI: 1760772206
Provider Name (Legal Business Name): SAMUEL DWIGHT GILLILAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12605 E 16TH AVE
AURORA CO
80045-2545
US

IV. Provider business mailing address

PO BOX 110429
AURORA CO
80042-0429
US

V. Phone/Fax

Practice location:
  • Phone: 720-848-0000
  • Fax:
Mailing address:
  • Phone: 303-493-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberDR.0056603
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: