Healthcare Provider Details

I. General information

NPI: 1417003989
Provider Name (Legal Business Name): JEFFERY DON GILLIAM PHYSICAL THERAPY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 NEWBERRY ROAD
GAINESVILLE FL
32607
US

IV. Provider business mailing address

7525 SW 47 LANE
GAINESVILLE FL
32608
US

V. Phone/Fax

Practice location:
  • Phone: 352-373-2116
  • Fax: 352-373-1507
Mailing address:
  • Phone: 352-335-4199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5040
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: