Provider Demographics
NPI:1215134820
Name:GILL, REBECCA ANN (MD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:GILL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:KNODE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:301 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5167
Mailing Address - Country:US
Mailing Address - Phone:386-231-3072
Mailing Address - Fax:
Practice Address - Street 1:600 PALMETTO ST STE 3
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7327
Practice Address - Country:US
Practice Address - Phone:386-428-8326
Practice Address - Fax:386-428-2493
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY47127208600000X
FLME129232208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100302490Medicaid
KYK158400Medicare PIN