Provider Demographics
NPI:1417040452
Name:GULBRANSON, ANGELA R (OD)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:R
Last Name:GULBRANSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 S. MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2559
Mailing Address - Country:US
Mailing Address - Phone:605-274-6717
Mailing Address - Fax:605-275-4804
Practice Address - Street 1:6201 S. MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2559
Practice Address - Country:US
Practice Address - Phone:605-274-6717
Practice Address - Fax:605-275-4804
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD565152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203264Medicaid
SD9203263Medicaid
SD9203263Medicaid