Healthcare Provider Details

I. General information

NPI: 1376509190
Provider Name (Legal Business Name): MARTIN E. GILLILAND M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W HOUSTON ST
JASPER TX
75951-4013
US

IV. Provider business mailing address

315 W HOUSTON ST
JASPER TX
75951-4013
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-3430
  • Fax: 409-383-0571
Mailing address:
  • Phone: 409-384-3430
  • Fax: 409-383-0571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ3107
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: