Healthcare Provider Details

I. General information

NPI: 1801864814
Provider Name (Legal Business Name): DOUGLAS L GERVAIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 OLSON MEMORIAL HWY #200
MINNEAPOLIS MN
55422
US

IV. Provider business mailing address

4825 OLSON MEMORIAL HWY #200
MINNEAPOLIS MN
55422
US

V. Phone/Fax

Practice location:
  • Phone: 763-545-0443
  • Fax: 763-545-2784
Mailing address:
  • Phone: 763-545-0443
  • Fax: 763-545-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number38691
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: