Provider Demographics
NPI:1962627984
Name:MCVAY GILLAM, MARCENE R (MD)
Entity type:Individual
Prefix:
First Name:MARCENE
Middle Name:R
Last Name:MCVAY GILLAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARCENE
Other - Middle Name:RENEE
Other - Last Name:MCVAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6908
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72766-6908
Mailing Address - Country:US
Mailing Address - Phone:501-349-3182
Mailing Address - Fax:
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-4000
Practice Address - Fax:210-358-4775
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3650208600000X, 2086S0120X
ARE-4933208600000X, 2086S0120X
OK422642086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery