Healthcare Provider Details

I. General information

NPI: 1902895329
Provider Name (Legal Business Name): DEREK ALLAN GEDLAMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 9TH ST W SUITE 12
COLUMBIA FALLS MT
59912-3859
US

IV. Provider business mailing address

734 9TH ST W SUITE 12
COLUMBIA FALLS MT
59912-3859
US

V. Phone/Fax

Practice location:
  • Phone: 406-892-1011
  • Fax: 406-892-2108
Mailing address:
  • Phone: 406-892-1011
  • Fax: 406-892-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10336
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: