Provider Demographics
NPI:1124133178
Name:IFILL, GORDON G (MD)
Entity type:Individual
Prefix:DR
First Name:GORDON
Middle Name:G
Last Name:IFILL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:836 E 65TH STREET
Mailing Address - Street 2:42 MEDICAL ARTS
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-966-3779
Mailing Address - Fax:912-963-2540
Practice Address - Street 1:836 E 65TH STREET
Practice Address - Street 2:42 MEDICAL ARTS
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405
Practice Address - Country:US
Practice Address - Phone:912-354-5780
Practice Address - Fax:912-354-5782
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2009-09-11
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Provider Licenses
StateLicense IDTaxonomies
GA0348592084P0800X
GA348592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA305328035AMedicaid
GA305328035AMedicaid