Healthcare Provider Details

I. General information

NPI: 1013343334
Provider Name (Legal Business Name): WILLIAM ALLEN GILLESPIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2013
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 MAIN ST
DURHAM CT
06422
US

IV. Provider business mailing address

256 MAIN ST
DURHAM CT
06422
US

V. Phone/Fax

Practice location:
  • Phone: 860-349-9434
  • Fax:
Mailing address:
  • Phone: 860-349-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number037591
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7879548
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: