Provider Demographics
NPI:1619288602
Name:GULLICKS, DONALD R (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:R
Last Name:GULLICKS
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:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:4000 28TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-7926
Practice Address - Country:US
Practice Address - Phone:701-234-3200
Practice Address - Fax:701-234-3239
Is Sole Proprietor?:No
Enumeration Date:2010-06-24
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020741207V00000X
MNTP107788207V00000X
ND13170207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN720219Medicare PIN
MNH400165233Medicare PIN
MNH400165227Medicare PIN
NDN720218Medicare PIN