Healthcare Provider Details

I. General information

NPI: 1063474336
Provider Name (Legal Business Name): THERESA MARY GILLE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US NAVAL HOSPITAL GUAM BLDG 50, FARENHOLT AVENUE
AGANAHEIGHTS, GUAM GU
96910
US

IV. Provider business mailing address

PSC 455 BOX 208
FPO AP
96540-0003
US

V. Phone/Fax

Practice location:
  • Phone: 671-344-9340
  • Fax:
Mailing address:
  • Phone: 671-682-8996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD-P-2023-002
License Number StateGU
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101240253
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: