Healthcare Provider Details

I. General information

NPI: 1891709630
Provider Name (Legal Business Name): JERRY N GILLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SE 17TH STREET SUITE 300
FORT LAUDERDALE FL
33316
US

IV. Provider business mailing address

1600 S. ANDREWS AVENUE SUITE 323 WEST WING
FORT LAUDERDALE FL
33316
US

V. Phone/Fax

Practice location:
  • Phone: 954-468-3080
  • Fax: 954-468-3082
Mailing address:
  • Phone: 954-355-5110
  • Fax: 954-355-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberME71247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: