Provider Demographics
NPI:1265547533
Name:DAVID L. GILBERTSON, DO, PA
Entity type:Organization
Organization Name:DAVID L. GILBERTSON, DO, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GILBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:651-646-2549
Mailing Address - Street 1:2315 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1723
Mailing Address - Country:US
Mailing Address - Phone:651-646-2549
Mailing Address - Fax:651-646-2480
Practice Address - Street 1:2315 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1723
Practice Address - Country:US
Practice Address - Phone:651-646-2549
Practice Address - Fax:651-646-2480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6251520261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN25Y48ANOtherBLUECROSS BLUESHIELD
MNCO2255Medicare ID - Type Unspecified