Healthcare Provider Details

I. General information

NPI: 1073575403
Provider Name (Legal Business Name): DANIEL J GASSERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 SOUTHPARK CIR E
ST AUGUSTINE FL
32086-5135
US

IV. Provider business mailing address

216 SOUTHPARK CIR E
ST AUGUSTINE FL
32086-5135
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-6108
  • Fax: 904-823-9613
Mailing address:
  • Phone: 904-824-6108
  • Fax: 904-823-9613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME0095376
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: