Provider Demographics
NPI:1053722264
Name:WOOLDRIDGE, GILLIAN (DO)
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:WOOLDRIDGE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 E. LEAGUE CITY PARKWAY, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573
Mailing Address - Country:US
Mailing Address - Phone:713-363-9090
Mailing Address - Fax:
Practice Address - Street 1:2220 E. LEAGUE CITY PARKWAY, SUITE 200
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573
Practice Address - Country:US
Practice Address - Phone:713-363-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-12
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR6136207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX584592OtherPERSONAL ID FOR TEXAS PIT PERMIT