Provider Demographics
NPI:1245264530
Name:GILMORE, CAROL A (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 4TH AVENUE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-4430
Mailing Address - Country:US
Mailing Address - Phone:619-691-1990
Mailing Address - Fax:619-691-5977
Practice Address - Street 1:450 4TH AVENUE
Practice Address - Street 2:SUITE 408
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-4430
Practice Address - Country:US
Practice Address - Phone:619-691-1990
Practice Address - Fax:619-691-5977
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41580207R00000X, 207Q00000X
WAMD00046332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWC41580BMedicare ID - Type Unspecified
A37637Medicare UPIN