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General NPI Number Information
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NPI Number | 1801864814
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Entity Type | Individual
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Provider Name | DOUGLAS L GERVAIS MD
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Gender | Male
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Dates
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Enumeration Date | 03/08/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4825 OLSON MEMORIAL HWY #200
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City | MINNEAPOLIS
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State | MN
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Zip | 55422
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Country | US
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Telephone | 763-545-0443
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Fax | 763-545-2784
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Provider Business Mailing Address
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Address Line | 4825 OLSON MEMORIAL HWY #200
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City | MINNEAPOLIS
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State | MN
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Zip | 55422
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Country | US
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Telephone | 763-545-0443
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Fax | 763-545-2784
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | 38691
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License Number State | MN
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