Basic Information
| Provider Information | |||||||||
| NPI: | 1285797639 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLENWATER | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 BURLEYSON DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062705002 | ||||||||
| FaxNumber: | 7062705111 | ||||||||
| Practice Location | |||||||||
| Address1: | 191 LAMAR HALEY PKWY | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301148019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707041600 | ||||||||
| FaxNumber: | 7707041610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2084P0800X | 043052 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.