Healthcare Provider Details

I. General information

NPI: 1548245392
Provider Name (Legal Business Name): ROGER ALAN GILMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3521 LIMBAUGH LN
PACE FL
32571-8789
US

IV. Provider business mailing address

3521 LIMBAUGH LN
PACE FL
32571-8789
US

V. Phone/Fax

Practice location:
  • Phone: 850-995-4798
  • Fax: 850-995-5776
Mailing address:
  • Phone: 850-995-4798
  • Fax: 850-995-5776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME 86621
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: