Provider Demographics
NPI:1730477449
Name:GILLAM, DIRCK ANTHONY
Entity type:Individual
Prefix:
First Name:DIRCK
Middle Name:ANTHONY
Last Name:GILLAM
Suffix:
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 1:2401 DIVISION ST APT E34
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70001-8805
Mailing Address - Country:US
Mailing Address - Phone:504-975-7102
Mailing Address - Fax:
Practice Address - Street 1:145 ELK PL
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2645
Practice Address - Country:US
Practice Address - Phone:504-525-0918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA045476390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program