Provider Demographics
NPI:1407830177
Name:GJERDRUM, THOR C (MD)
Entity Type:Individual
Prefix:DR
First Name:THOR
Middle Name:C
Last Name:GJERDRUM
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 1:504 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6917
Mailing Address - Country:US
Mailing Address - Phone:805-739-3863
Mailing Address - Fax:805-614-2035
Practice Address - Street 1:300 SOUTH STRATFORD AVENUE
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5903
Practice Address - Country:US
Practice Address - Phone:805-739-3863
Practice Address - Fax:805-614-2035
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16055207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG16055IOtherMEDICARE ID
CAZZZ06481ZOtherBLUE SHIELD GROUP PIN
CA00G160550Medicaid
CA00G160550Medicaid
CAZZZ06481ZOtherBLUE SHIELD GROUP PIN