Provider Demographics
NPI:1376587691
Name:MINDRUM, GERALD G (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:G
Last Name:MINDRUM
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 1:1435 WATERFORD DR
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4274
Mailing Address - Country:US
Mailing Address - Phone:763-587-9561
Mailing Address - Fax:
Practice Address - Street 1:1435 WATERFORD DR
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4274
Practice Address - Country:US
Practice Address - Phone:763-587-9561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15992207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNG44643Medicare UPIN