Healthcare Provider Details

I. General information

NPI: 1649235532
Provider Name (Legal Business Name): STEPHEN R GILLILAND MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8813 S 71ST EAST AVE
TULSA OK
74133-5056
US

IV. Provider business mailing address

8813 S 71ST EAST AVE
TULSA OK
74133-5056
US

V. Phone/Fax

Practice location:
  • Phone: 918-809-0712
  • Fax: 918-524-6055
Mailing address:
  • Phone: 918-809-0712
  • Fax: 918-524-6055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number10961
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: