Basic Information
Provider Information
NPI: 1710486295
EntityType: 2
ReplacementNPI:  
OrganizationName: GASTRO MD, LLC
LastName:  
FirstName:  
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Credential:  
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Mailing Information
Address1: 625 RICHLAND WAY
Address2:  
City: WESTFIELD
State: IN
PostalCode: 460749054
CountryCode: US
TelephoneNumber: 2604078009
FaxNumber: 2604078009
Practice Location
Address1: 625 RICHLAND WAY
Address2:  
City: WESTFIELD
State: IN
PostalCode: 460749054
CountryCode: US
TelephoneNumber: 2604078009
FaxNumber: 2604078009
Other Information
ProviderEnumerationDate: 02/09/2018
LastUpdateDate: 02/09/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: AHMAD
AuthorizedOfficialFirstName: USMAN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 4192906412
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RG0100X01077429AINN193400000X MULTIPLE SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
207R00000X01077429AINY193400000X MULTIPLE SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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