Provider Demographics
NPI:1164424586
Name:GJESDAL, SHANE MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANE
Middle Name:MATTHEW
Last Name:GJESDAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1188
Mailing Address - Country:US
Mailing Address - Phone:541-812-4850
Mailing Address - Fax:
Practice Address - Street 1:705 ELM ST SW
Practice Address - Street 2:SUITE 200
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1956
Practice Address - Country:US
Practice Address - Phone:541-812-4850
Practice Address - Fax:541-812-4889
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD29109207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology