Provider Demographics
NPI:1285659714
Name:GERDTS, CORAL (DPM)
Entity Type:Individual
Prefix:
First Name:CORAL
Middle Name:
Last Name:GERDTS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:300 UTAH ST
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:KS
Practice Address - Zip Code:66434-2314
Practice Address - Country:US
Practice Address - Phone:785-742-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12-0311213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS114052OtherBLUE CROSS OF KS
NE25014OtherBLUE CROSS
KS100369010AMedicaid
NE25014OtherBLUE CROSS
KS100369010AMedicaid
NE273036GEMedicare PIN
KS480030960Medicare ID - Type UnspecifiedRAILROAD MEDICARE
KS114052Medicare PIN