Provider Demographics
NPI:1871083378
Name:GILDE, ETHAN (DO)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:GILDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27555 MIDDLEBELT RD.
Mailing Address - Street 2:
Mailing Address - City:FAMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334
Mailing Address - Country:US
Mailing Address - Phone:248-478-5512
Mailing Address - Fax:245-478-5350
Practice Address - Street 1:27555 MIDDLEBELT RD.
Practice Address - Street 2:
Practice Address - City:FAMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334
Practice Address - Country:US
Practice Address - Phone:248-478-5512
Practice Address - Fax:245-478-5350
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.0160182084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0306635Medicaid