Provider Demographics
NPI:1225223670
Name:GAUDERMAN, THOMAS EDWARD (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:EDWARD
Last Name:GAUDERMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 UNIVERSITY AVE W STE 306
Mailing Address - Street 2:SPRUCE TREE CENTRE
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 306
Practice Address - Street 2:SPRUCE TREE CENTRE
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3922
Practice Address - Country:US
Practice Address - Phone:941-552-1189
Practice Address - Fax:941-365-8635
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor