Provider Demographics
NPI:1750491270
Name:CHRISTIANSEN, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:CHRISTIANSEN
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 1:2820 MOUNT RUSHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5462
Mailing Address - Country:US
Mailing Address - Phone:605-342-3280
Mailing Address - Fax:605-721-8458
Practice Address - Street 1:2820 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5462
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:605-348-0662
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4012208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY310365OtherBLUE CROSS BLUE SHIELD
SD7500340Medicaid
WY111516200Medicaid
SD21395OtherSANFORD HEALTH
SD4012OtherDAKOTACARE
SD0004134OtherBLUE CROSS BLUE SHIELD
SDS4134OtherSD MEDICARE
SD21395OtherSIOUX VALLEY HEALTH PLAN
SD4012OtherDAKOTACARE
SD7500340Medicaid
WY310365OtherBLUE CROSS BLUE SHIELD
340011571Medicare ID - Type UnspecifiedRAILROAD