Healthcare Provider Details

I. General information

NPI: 1578504726
Provider Name (Legal Business Name): GILSON JOHN KINGMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 MAPLEWOOD AVE
WINSTON SALEM NC
27103
US

IV. Provider business mailing address

2901 MAPLEWOOD AVE
WINSTON SALEM NC
27103
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-8620
  • Fax: 336-768-6236
Mailing address:
  • Phone: 336-765-8620
  • Fax: 336-768-6236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number200001205450
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: