Provider Demographics
NPI:1376639476
Name:GANDER, STEVEN PHILLIP (OD)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:PHILLIP
Last Name:GANDER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 8TH ST. SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND FORKS
Mailing Address - State:MN
Mailing Address - Zip Code:56721
Mailing Address - Country:US
Mailing Address - Phone:218-773-3447
Mailing Address - Fax:
Practice Address - Street 1:421 DEMERS AVE. NW
Practice Address - Street 2:
Practice Address - City:EAST GRAND FORKS
Practice Address - State:MN
Practice Address - Zip Code:56721
Practice Address - Country:US
Practice Address - Phone:218-773-3438
Practice Address - Fax:218-773-1645
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2128152W00000X
ND458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60457Medicaid
C36243Medicare UPIN
ND60457Medicaid