Provider Demographics
NPI:1801864814
Name:GERVAIS, DOUGLAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:GERVAIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4825 OLSON MEMORIAL HWY
Mailing Address - Street 2:#200
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422
Mailing Address - Country:US
Mailing Address - Phone:763-545-0443
Mailing Address - Fax:763-545-2784
Practice Address - Street 1:4825 OLSON MEMORIAL HWY
Practice Address - Street 2:#200
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422
Practice Address - Country:US
Practice Address - Phone:763-545-0443
Practice Address - Fax:763-545-2784
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN38691208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN17A56GEOtherBLUE CROSS
G29022Medicare UPIN