Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 0101047505 | VA |
NPI | 1053309229 |
---|---|
Provider Name | Charles Buckley Gillock |
First Address | Roanoke, VA 24014-0310 |
Second Address | Fishersville, VA 22939-2273 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2005 |
Last Update Date | 25/10/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
007501188 | (05) | VA |
279040 | BCBS ANTHEM (01) | VA |
G25454 | (02) |