Healthcare Provider Details

I. General information

NPI: 1376617159
Provider Name (Legal Business Name): DAVID GILLINGHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 02/04/2022
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 COOPER POINT ROAD NW PMG SW WA W OLYMPIA FAM MED
OLYMPIA WA
98502
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-486-6710
  • Fax: 360-956-1643
Mailing address:
  • Phone: 360-486-6508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00001138
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: