Provider Demographics
NPI:1194743302
Name:GILLIARD, TAWANNA OPAL (MD)
Entity type:Individual
Prefix:DR
First Name:TAWANNA
Middle Name:OPAL
Last Name:GILLIARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TAWANNA
Other - Middle Name:O
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7130 GLEN FOREST DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3754
Mailing Address - Country:US
Mailing Address - Phone:804-282-1095
Mailing Address - Fax:804-282-8678
Practice Address - Street 1:7611 FOREST AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-4946
Practice Address - Country:US
Practice Address - Phone:804-288-4084
Practice Address - Fax:804-288-3567
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055753207V00000X
VA0101244776207V00000X
PAMD424859207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101244776OtherLICENSE NUMBER
GA055753OtherLICENSE #
VA1194743302Medicaid
GA964207974AMedicaid
GA964207974AMedicaid
GA964207974AMedicaid
VA1194743302Medicaid
VAVV1179AMedicare PIN