Basic Information
| Provider Information | |||||||||
| NPI: | 1902016306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILL | ||||||||
| FirstName: | KIRANDEEP | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1090 NORTH PARK PLACE | ||||||||
| Address2: | |||||||||
| City: | COEUR D'ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082920292 | ||||||||
| FaxNumber: | 2082920705 | ||||||||
| Practice Location | |||||||||
| Address1: | 1090 NORTH PARK PLACE | ||||||||
| Address2: | |||||||||
| City: | COEUR D'ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082920292 | ||||||||
| FaxNumber: | 2082920705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 10/04/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20A11328 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 20A11328 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.