Provider Demographics
NPI:1194788497
Name:GAERTNER, JOHNN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNN
Middle Name:R
Last Name:GAERTNER
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 1:651 ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4518
Mailing Address - Country:US
Mailing Address - Phone:651-793-3100
Mailing Address - Fax:651-793-3133
Practice Address - Street 1:651 ARCADE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-4518
Practice Address - Country:US
Practice Address - Phone:651-793-3100
Practice Address - Fax:651-793-3133
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15861207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245777600Medicaid
MNA93701Medicare UPIN
MN080012649Medicare ID - Type Unspecified