Individual
FRED GILLIAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
HAS
Contact information
Practice address
742 N VOLUSIA AVE, ORANGE CITY, FL 32763-4857
(386) 561-9496
Mailing address
5680 WINONA TRL, DE LEON SPRINGS, FL 32130-3613
(386) 717-1621
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
AS4847
FL
Other
Enumeration date
11/19/2012
Last updated
03/14/2014
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