Provider Demographics
NPI:1144331083
Name:GILLESPIE, W. BRENT (DPM)
Entity type:Individual
Prefix:DR
First Name:W.
Middle Name:BRENT
Last Name:GILLESPIE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19222 STONEHUE STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3454
Mailing Address - Country:US
Mailing Address - Phone:210-490-6408
Mailing Address - Fax:210-490-6419
Practice Address - Street 1:19222 STONEHUE STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3454
Practice Address - Country:US
Practice Address - Phone:210-490-6408
Practice Address - Fax:210-490-6419
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1084213E00000X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127195904Medicaid
TXT83576Medicare UPIN
TX127195904Medicaid