Basic Information
| Provider Information | |||||||||
| NPI: | 1255715579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIHAN | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 208313 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753208313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207775030 | ||||||||
| FaxNumber: | 5205094496 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 S MCCLINTOCK DR STE 115 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807758460 | ||||||||
| FaxNumber: | 4807758464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2015 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 000904 | AZ | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | POD-000904 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 413038 | 05 | AZ | MEDICAID |