Healthcare Provider Details

I. General information

NPI: 1629330071
Provider Name (Legal Business Name): ISAAC GATWOOD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26020 STATE ROAD 145
BRISTOW IN
47515
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-357-2097
  • Fax:
Mailing address:
  • Phone: 812-996-1088
  • Fax: 812-996-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11016756A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: