Healthcare Provider Details

I. General information

NPI: 1184794331
Provider Name (Legal Business Name): VICTOR MARCEL GELLINEAU III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 CAPITAL BLVD
RALEIGH NC
27604-4478
US

IV. Provider business mailing address

PO BOX 746724
ATLANTA GA
30374-6724
US

V. Phone/Fax

Practice location:
  • Phone: 919-980-7008
  • Fax: 919-336-4528
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2021-02186
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA75952
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: