Provider Demographics
NPI:1053426171
Name:GOTTENBORG, DAVID WAYNE (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
Last Name:GOTTENBORG
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 385
Mailing Address - Street 2:
Mailing Address - City:PELICAN RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56572
Mailing Address - Country:US
Mailing Address - Phone:218-863-2134
Mailing Address - Fax:218-863-2135
Practice Address - Street 1:12 5TH AVE. NE
Practice Address - Street 2:
Practice Address - City:PELICAN RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56572
Practice Address - Country:US
Practice Address - Phone:218-863-2134
Practice Address - Fax:218-863-2135
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1952111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN61177GOOtherBLUE CROSS BLUE SHIELD MN
MNT65548Medicare UPIN