Provider Demographics
NPI:1992712616
Name:GILL, VIVEK S (MD)
Entity type:Individual
Prefix:
First Name:VIVEK
Middle Name:S
Last Name:GILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9723 SIERRA VISTA RD
Mailing Address - Street 2:UNIT A
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92371-8271
Mailing Address - Country:US
Mailing Address - Phone:760-868-1990
Mailing Address - Fax:760-868-1201
Practice Address - Street 1:9723 SIERRA VISTA RD
Practice Address - Street 2:UNIT A
Practice Address - City:PHELAN
Practice Address - State:CA
Practice Address - Zip Code:92371-8271
Practice Address - Country:US
Practice Address - Phone:760-868-1990
Practice Address - Fax:760-868-1201
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2010-04-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA610540207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A610540Medicaid
CA00A610540Medicaid
CABB046Medicare PIN