Provider Demographics
NPI:1588965693
Name:GILLIS, TOM M (MD)
Entity type:Individual
Prefix:DR
First Name:TOM
Middle Name:M
Last Name:GILLIS
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 1:20701 N SCOTTSDALE RD
Mailing Address - Street 2:UNIT 107 SUITE 196
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-6413
Mailing Address - Country:US
Mailing Address - Phone:480-247-6301
Mailing Address - Fax:480-247-6301
Practice Address - Street 1:20701 N SCOTTSDALE RD
Practice Address - Street 2:UNIT 107 SUITE 196
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6413
Practice Address - Country:US
Practice Address - Phone:480-247-6301
Practice Address - Fax:480-247-6301
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35983174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ35983OtherARIZONA MEDICAL BOARD