Provider Demographics
NPI:1205054228
Name:GABRIELSEN, TED HOWARD (MD)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:HOWARD
Last Name:GABRIELSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:0NE MEMORIAL SQUARE
Mailing Address - Street 2:SUITE - 100
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-2819
Mailing Address - Country:US
Mailing Address - Phone:317-462-3255
Mailing Address - Fax:317-477-6334
Practice Address - Street 1:1 MEMORIAL SQ
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-2835
Practice Address - Country:US
Practice Address - Phone:317-462-3255
Practice Address - Fax:317-477-6334
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-02-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01019182208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100127360AMedicaid
IN320690AMedicare ID - Type Unspecified
IN100127360AMedicaid