Healthcare Provider Details

I. General information

NPI: 1336195148
Provider Name (Legal Business Name): BRIAN DAVID ZELICKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NICOLLET MALL SUITE 1002
MINNEAPOLIS MN
55402-2606
US

IV. Provider business mailing address

825 NICOLLET MALL SUITE 1002
MINNEAPOLIS MN
55402-2606
US

V. Phone/Fax

Practice location:
  • Phone: 612-338-0711
  • Fax: 612-332-3663
Mailing address:
  • Phone: 612-338-0711
  • Fax: 612-332-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number31389
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: