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General NPI Number Information
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NPI Number | 1215315858
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Entity Type | Individual
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Provider Name | SUSAN ELIZABETH GILLIS MD
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Gender | Female
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Dates
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Enumeration Date | 05/15/2015
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Last Update Date | 08/26/2024
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Provider Practice Location Address
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Address Line | 25500 RANCHO NIGUEL RD STE 110
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City | LAGUNA NIGUEL
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State | CA
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Zip | 92677-7373
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Country | US
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Telephone | 949-448-8821
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Fax |
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Provider Business Mailing Address
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Address Line | 3200 PASEO VILLAGE WAY APT 1321
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City | SAN DIEGO
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State | CA
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Zip | 92130-3232
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Country | US
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Telephone | 260-241-5700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A172110
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License Number State | CA
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