Basic Information
| Provider Information | |||||||||
| NPI: | 1619288602 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GULLICKS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2168 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581072168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342119 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4000 28TH AVE S | ||||||||
| Address2: | |||||||||
| City: | MOORHEAD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565607926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012343200 | ||||||||
| FaxNumber: | 7012343239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2010 | ||||||||
| LastUpdateDate: | 10/22/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 2010020741 | MO | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | TP107788 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 13170 | ND | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.