Individual
DR. JEREMY D GILLIAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
5001 US HIGHWAY 30 W STE D, FORT WAYNE, IN 46818-9701
(260) 432-4969
(260) 432-4969
Mailing address
PO BOX 80070, FORT WAYNE, IN 46898-0070
(260) 432-1568
(260) 432-4969
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
01064785A
IN
2085R0202X
Diagnostic Radiology Physician
35.091145
OH
2085R0202X
Diagnostic Radiology Physician
R1044
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1538284153
—
MI
05
—
200939030
—
IN
05
—
2840742
—
OH
Enumeration date
03/20/2007
Last updated
06/20/2016
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