Provider Demographics
NPI:1871521906
Name:GILL, STEPHEN BOYD (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:BOYD
Last Name:GILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:2349 VILLAGE SQUARE PKWY STE 110
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4319
Practice Address - Country:US
Practice Address - Phone:904-264-6404
Practice Address - Fax:904-264-6884
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL268474800Medicaid
FLP00464116OtherRAILROAD MEDICARE
FL268474800Medicaid
FL15612VMedicare PIN
FL15612OtherBLUE CROSS BLUE SHIELD
FL269050100OtherMEDIPASS