Provider Demographics
NPI:1538201629
Name:GILLIAM, RYAN DWAIN (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:DWAIN
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-713-0947
Mailing Address - Fax:
Practice Address - Street 1:2311 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8905
Practice Address - Country:US
Practice Address - Phone:336-713-8900
Practice Address - Fax:336-702-9286
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRTL207Q00000X
NC200901294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5912191Medicaid
NC2074047Medicare PIN