Healthcare Provider Details

I. General information

NPI: 1063472017
Provider Name (Legal Business Name): CARL K GJERTSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE UROLOGY
FARMINGTON CT
06030-6227
US

IV. Provider business mailing address

331 NEWMAN SPRINGS ROAD BLDG. 2, SUITE 220
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4100
  • Fax: 860-679-1390
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number045171
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA12258300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number045171
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: