Healthcare Provider Details

I. General information

NPI: 1679770176
Provider Name (Legal Business Name): RAJI M GILL DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E DOWNING ST STE 100
TAHLEQUAH OK
74464-3354
US

IV. Provider business mailing address

1500 EAST DOWNING SUITE 100
TAHLEQUAH OK
74404
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-5700
  • Fax: 918-458-5790
Mailing address:
  • Phone: 918-458-5700
  • Fax: 918-458-5790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number3753
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100125770A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier684532300
Identifier TypeOTHER
Identifier State
Identifier IssuerDEPT OF LABOR

VIII. Authorized Official

Name: DR. RAJI M GILL
Title or Position: PRESIDENT
Credential: DO
Phone: 918-458-5700