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General NPI Number Information
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NPI Number | 1255960357
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Entity Type | Individual
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Provider Name | NICHOLAS GILLIAM DO
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Gender | Male
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Dates
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Enumeration Date | 04/02/2020
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 200 AVENUE F NE
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City | WINTER HAVEN
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State | FL
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Zip | 33881-4131
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Country | US
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Telephone | 800-229-2273
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Fax |
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Provider Business Mailing Address
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Address Line | 2995 DREW ST FL 2
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City | CLEARWATER
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State | FL
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Zip | 33759-3012
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Country | US
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Telephone | 727-315-7496
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | OS21066
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 34.016963
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License Number State | OH
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