Individual
ROBERT TODD GILLESPIE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
220 BANNOCK ST, SUITE B, MALAD CITY, ID 83252-1256
(208) 766-2600
Mailing address
PO BOX 126, SUITE B, MALAD CITY, ID 83252-0126
(208) 766-2231
(208) 766-4819
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA205
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
805203600
—
ID
01
—
970011284
RAILROAD MEDICARE PTAN
ID
Enumeration date
07/17/2006
Last updated
06/10/2011
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