Provider Demographics
NPI:1760062616
Name:GILLUM, ROGER DEAN (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:DEAN
Last Name:GILLUM
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 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-758-2294
Mailing Address - Fax:501-758-7877
Practice Address - Street 1:2508 CRESTWOOD RD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72116-7623
Practice Address - Country:US
Practice Address - Phone:501-758-2294
Practice Address - Fax:501-758-7877
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-17057207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program