Healthcare Provider Details

I. General information

NPI: 1922181593
Provider Name (Legal Business Name): RAJI M GILL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RAJINDER S GILL DO

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 EAST DOWNING SUITE 100
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

1500 EAST DOWNING SUITE 100
TAHLEQUAH OK
74464
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
Identifier604532300
Identifier TypeOTHER
Identifier State
Identifier IssuerDEPT OF LABOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: