Provider Demographics
NPI:1790738516
Name:GILBERTSON, JEFFERY J (MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:J
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 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:333 N 1ST ST
Practice Address - Street 2:SUITE 280
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6100
Practice Address - Country:US
Practice Address - Phone:208-345-6545
Practice Address - Fax:208-345-1213
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-59042086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000303Medicare PIN