Basic Information
| Provider Information | |||||||||
| NPI: | 1225427826 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLAM | ||||||||
| FirstName: | JOHN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4175 VETERANS MEMORIAL HWY | ||||||||
| Address2: | STE 202 | ||||||||
| City: | RONKONKOMA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117797639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | 6315805222 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 WALLACE BLVD | ||||||||
| Address2: | SUITE E | ||||||||
| City: | CINNAMINSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080772578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568290015 | ||||||||
| FaxNumber: | 8568290043 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2015 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01495300 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.