Basic Information
| Provider Information | |||||||||
| NPI: | 1578543617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLAN | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23500 US HIGHWAY 160 | ||||||||
| Address2: | |||||||||
| City: | WALSENBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810899524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197385100 | ||||||||
| FaxNumber: | 7197385138 | ||||||||
| Practice Location | |||||||||
| Address1: | 23450 US HIGHWAY 160 | ||||||||
| Address2: | |||||||||
| City: | WALSENBURG | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810899104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197384588 | ||||||||
| FaxNumber: | 7197384534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 01/03/2014 | ||||||||
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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 | 208600000X | 33569 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD2012-0389 | NM | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 53050 | CO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 911190 | 05 | AZ | MEDICAID |