Provider Demographics
NPI:1568412229
Name:MARK GERSTBERGER DO LLC
Entity Type:Organization
Organization Name:MARK GERSTBERGER DO LLC
Other - Org Name:GERSTBERGER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-356-2432
Mailing Address - Street 1:301 E GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-2515
Mailing Address - Country:US
Mailing Address - Phone:620-356-2432
Mailing Address - Fax:620-356-4050
Practice Address - Street 1:301 E GRANT AVE
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2515
Practice Address - Country:US
Practice Address - Phone:620-356-2432
Practice Address - Fax:620-356-4050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-26485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty