Basic Information
| Provider Information | |||||||||
| NPI: | 1598756579 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLETTE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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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 | C29328 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | C29328 | 01 | CA | PROFESSIONAL LICENSE # | OTHER | ZZZ91891Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | ZZZ91892Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | 00C293280 | 05 | CA | MEDICAID | AG4698671 | 01 | CA | DEA# | OTHER | ZZZ92069Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER |