Healthcare Provider Details

I. General information

NPI: 1073260881
Provider Name (Legal Business Name): ROY THOMAS GILDERSLEEVE III DO, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST SPC BASE
COLORADO SPRINGS CO
80914-1541
US

IV. Provider business mailing address

559 VINCENT ST SPC BASE
COLORADO SPRINGS CO
80914-1541
US

V. Phone/Fax

Practice location:
  • Phone: 719-556-7804
  • Fax:
Mailing address:
  • Phone: 719-556-7804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0102208425
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: