Provider Demographics
NPI:1124080056
Name:GULLICKSON, DONALD E II (DO)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:E
Last Name:GULLICKSON
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 COLVIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1107
Mailing Address - Country:US
Mailing Address - Phone:716-874-2150
Mailing Address - Fax:716-874-6765
Practice Address - Street 1:1783 COLVIN BLVD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223-1107
Practice Address - Country:US
Practice Address - Phone:716-874-2150
Practice Address - Fax:716-874-6765
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186403207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1295587Medicaid
BB2387Medicare ID - Type Unspecified
NY1295587Medicaid