Provider Demographics
NPI:1306863261
Name:GILBERTSON, KIMBERLY A (OD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:GILBERTSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4939
Practice Address - Country:US
Practice Address - Phone:701-461-5100
Practice Address - Fax:701-234-7060
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND562152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60513Medicaid
NDN716191Medicare PIN
NDN15089Medicare PIN
U66604Medicare UPIN