Provider Demographics
NPI:1487602306
Name:GILLIGAN, THOMAS LEE (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LEE
Last Name:GILLIGAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 WELLS ST
Mailing Address - Street 2:
Mailing Address - City:SISTERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26175-1323
Mailing Address - Country:US
Mailing Address - Phone:304-652-1077
Mailing Address - Fax:304-652-1028
Practice Address - Street 1:617 WELLS ST
Practice Address - Street 2:
Practice Address - City:SISTERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26175-1323
Practice Address - Country:US
Practice Address - Phone:304-652-1077
Practice Address - Fax:304-652-1028
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0049379000Medicaid
WV0461813Medicare ID - Type Unspecified
WV0049379000Medicaid