Healthcare Provider Details

I. General information

NPI: 1558582742
Provider Name (Legal Business Name): MARY JANE GAST RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 W 22ND ST STE 210
ANDERSON IN
46016-4389
US

IV. Provider business mailing address

10330 N MERIDIAN ST # 300
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 765-646-8795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37000680A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: