Healthcare Provider Details

I. General information

NPI: 1154582716
Provider Name (Legal Business Name): KORY LEE GILL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 UNIVERSITY DR E STE 100
BRYAN TX
77802-3499
US

IV. Provider business mailing address

2900 E 29TH ST
BRYAN TX
77802-2622
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-0169
  • Fax: 979-776-1372
Mailing address:
  • Phone: 979-776-8440
  • Fax: 979-776-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM8674
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberM8674
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: