Provider Demographics
NPI:1154754489
Name:ANGELA R. GULBRANSON OD, PC
Entity type:Organization
Organization Name:ANGELA R. GULBRANSON OD, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:PULFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-274-6717
Mailing Address - Street 1:6205 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2559
Mailing Address - Country:US
Mailing Address - Phone:605-271-7100
Mailing Address - Fax:605-271-7781
Practice Address - Street 1:6205 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2559
Practice Address - Country:US
Practice Address - Phone:605-271-7100
Practice Address - Fax:605-271-7781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANGELA R. GULBRANSON, OD P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-09
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD565152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203263Medicaid
SD9203263Medicaid