Provider Demographics
NPI:1962516575
Name:GILBERTSON, DAVID LEE (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
Last Name:GILBERTSON
Suffix:
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 1:2315 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1723
Mailing Address - Country:US
Mailing Address - Phone:651-646-2549
Mailing Address - Fax:651-646-2480
Practice Address - Street 1:17645 JUNIPER PATH STE 155
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-7577
Practice Address - Country:US
Practice Address - Phone:952-898-1022
Practice Address - Fax:952-898-4006
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18265207Q00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN25Y49GIOtherBLUECROSS BLUESHIELD
MN01889OtherMEDICA
MN105750OtherUCARE
MN1000738OtherPREFERRED ONE
MN1000738OtherPREFERRED ONE