Provider Demographics
NPI:1477822955
Name:GULBRANDSEN, ERIK PAUL (DO)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:PAUL
Last Name:GULBRANDSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 KANE DR
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-2534
Mailing Address - Country:US
Mailing Address - Phone:618-319-4291
Mailing Address - Fax:
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-536-6621
Practice Address - Fax:618-453-1102
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125056713207Q00000X
UT8247212-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine