Healthcare Provider Details

I. General information

NPI: 1578848792
Provider Name (Legal Business Name): JUSTIN JOHN GASPER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 ANDERSON HEALTHCARE DR
EDWARDSVILLE IL
62025-7712
US

IV. Provider business mailing address

1776 WOODSTEAD CT STE 208
THE WOODLANDS TX
77380-1480
US

V. Phone/Fax

Practice location:
  • Phone: 618-307-7900
  • Fax:
Mailing address:
  • Phone: 877-749-7428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036.167006
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0102203750
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberBP10040290
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2015011363
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number2015011363
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number036.167006
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: