Provider Demographics
NPI:1912956590
Name:GABRIELSON, GLEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:GABRIELSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1891 HONEYSUCKLE RD
Mailing Address - Street 2:STE C2
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305
Mailing Address - Country:US
Mailing Address - Phone:334-794-6504
Mailing Address - Fax:334-793-4452
Practice Address - Street 1:1891 HONEYSUCKLE RD
Practice Address - Street 2:STE C2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305
Practice Address - Country:US
Practice Address - Phone:334-794-6504
Practice Address - Fax:334-793-4452
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00012449207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000015369Medicaid
AL51523143OtherBLUE CROSS
AL000015369Medicare PIN
AL000015369Medicaid
AL51523143OtherBLUE CROSS