Healthcare Provider Details

I. General information

NPI: 1790002954
Provider Name (Legal Business Name): JOHN W GILLESPIE III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2383 LIMESTONE RD 2ND FL
WILMINGTON DE
19808
US

IV. Provider business mailing address

2383 LIMESTONE RD 2ND FL
WILMINGTON DE
19808
US

V. Phone/Fax

Practice location:
  • Phone: 302-274-2996
  • Fax: 302-274-2987
Mailing address:
  • Phone: 302-274-2996
  • Fax: 302-274-2987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberC1-0012570
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1790002954
License Number StateDE
# 3
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberC10012570
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: