Provider Demographics
NPI:1962779256
Name:GILLIAM, BARRY LEE JR
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:LEE
Last Name:GILLIAM
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-943-2273
Mailing Address - Fax:405-947-8262
Practice Address - Street 1:4100 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6334
Practice Address - Country:US
Practice Address - Phone:405-943-2273
Practice Address - Fax:405-947-8262
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator