Provider Demographics
NPI:1831190867
Name:GILL, ROY D (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:D
Last Name:GILL
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 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-2209
Practice Address - Street 1:507 MAIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1810
Practice Address - Country:US
Practice Address - Phone:607-763-8008
Practice Address - Fax:607-763-8019
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112978-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00411330Medicaid
NYBB4479Medicare PIN
NY00411330Medicaid