Provider Demographics
NPI:1457356099
Name:KARLSTAD, GARY L (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:KARLSTAD
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 1:3035 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4018
Mailing Address - Country:US
Mailing Address - Phone:701-775-3151
Mailing Address - Fax:701-775-3153
Practice Address - Street 1:3035 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4018
Practice Address - Country:US
Practice Address - Phone:701-775-3151
Practice Address - Fax:701-775-3153
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-20
Last Update Date:2007-07-08
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
ND4071174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1801OtherND BLUE SHIELD
ND12809Medicaid
ND12809Medicaid
ND1801Medicare ID - Type Unspecified