Provider Demographics
NPI:1366538076
Name:GILBERTSON, PHILLIP ROY (MD)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:ROY
Last Name:GILBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8204 WYOMING HIGHWAY 789
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-2941
Mailing Address - Country:US
Mailing Address - Phone:307-335-6716
Mailing Address - Fax:307-335-6991
Practice Address - Street 1:8204 WYOMING HWY 789
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-2945
Practice Address - Country:US
Practice Address - Phone:307-335-6716
Practice Address - Fax:307-335-6991
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2459A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY105078800Medicaid
WI080035569OtherMEDICARE RAILROAD RETIRE
WY301811OtherBLUE SHIELD
WYW301811Medicare ID - Type Unspecified
WY105078800Medicaid