Provider Demographics
NPI:1275725897
Name:GILMORE, NATHAN THOMAS (MD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMAS
Last Name:GILMORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOAG DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4162
Mailing Address - Country:US
Mailing Address - Phone:801-330-9242
Mailing Address - Fax:
Practice Address - Street 1:35410 DEL REY
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92624-1814
Practice Address - Country:US
Practice Address - Phone:801-330-9242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126324207PE0004X
PAMD438336207PE0004X
UT7605335-1205207P00000X
FLME113517207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023805290002Medicaid
PA1023805290002Medicaid
PA168609Medicare PIN