Provider Demographics
NPI:1174566558
Name:GILLIAM, THEOPOLIS JR (MD)
Entity type:Individual
Prefix:
First Name:THEOPOLIS
Middle Name:
Last Name:GILLIAM
Suffix:JR
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 1:8580 MAGELLAN PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-1149
Mailing Address - Country:US
Mailing Address - Phone:804-765-6650
Mailing Address - Fax:804-765-6651
Practice Address - Street 1:702 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1242
Practice Address - Country:US
Practice Address - Phone:434-594-6603
Practice Address - Fax:804-765-6651
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101041278207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA187123OtherBLUE SHIELD
6919392OtherCIGNA
VA005818613Medicaid
VA187123OtherBLUE SHIELD
110003614Medicare PIN