Basic Information
| Provider Information | |||||||||
| NPI: | 1518953934 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAST | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 SANDPOINT RD | ||||||||
| Address2: | |||||||||
| City: | MUNISING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498621406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063874338 | ||||||||
| FaxNumber: | 9063872825 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 GRACELAWN RD | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042106334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073334799 | ||||||||
| FaxNumber: | 2073334767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4301051117 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 0690010 | 01 | MI | BLUE SHIELD | OTHER | 1518953934 | 05 | ME | MEDICAID | 2855852 | 05 | MI | MEDICAID |