Provider Demographics
NPI:1336195148
Name:ZELICKSON, BRIAN DAVID (MD)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
Last Name:ZELICKSON
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 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 1002
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2606
Mailing Address - Country:US
Mailing Address - Phone:612-338-0711
Mailing Address - Fax:612-332-3663
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 1002
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-338-0711
Practice Address - Fax:612-332-3663
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31389207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3683231-00Medicaid
E38510Medicare UPIN
MN3683231-00Medicaid