Provider Demographics
NPI:1598792939
Name:GILBERTSON, ROGER L (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:GILBERTSON
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 1:737 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58122-0001
Mailing Address - Country:US
Mailing Address - Phone:701-234-6960
Mailing Address - Fax:701-234-6979
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58122-0001
Practice Address - Country:US
Practice Address - Phone:701-234-6960
Practice Address - Fax:701-234-6979
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND31522085R0202X
MN165752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
4617OtherNDBC
HP10479OtherHEALTHPARTNERS
ND12364Medicaid
1624696OtherMEDICA
895001OtherPREFERRED ONE
90926GIOtherMNBC
ND12364Medicaid
HP10479OtherHEALTHPARTNERS