MEDICARE: THOMAS ENGEL GILLEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	G22765	CA

General Provider Information

NPI Number	:	1902170749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS ENGEL GILLEN M.D.

Provider Business Mailing Address
First Line	:	4211 SHOREPOINTE WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-8634
Country	:	US
Telephone Number	:	858-610-9147
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 SHOREPOINTE WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-8634
Country	:	US
Telephone Number	:	858-610-9147
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2012
Last Update Date	:	02/24/2012

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