Provider Demographics
NPI:1316514953
Name:GILLISPIE, ALEXANDRA (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 FEELY LN
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545-9762
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:736 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2907
Practice Address - Country:US
Practice Address - Phone:617-789-2990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA289647208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program