Provider Demographics
NPI:1811150923
Name:GILBERTSON, KENNETH GERARD II (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:GERARD
Last Name:GILBERTSON
Suffix:II
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:6815 118TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8420
Practice Address - Country:US
Practice Address - Phone:262-857-5600
Practice Address - Fax:262-857-1171
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56044207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100017150Medicaid
WIP01084488OtherRR MEDICARE
WIP01084488OtherRR MEDICARE