Healthcare Provider Details

I. General information

NPI: 1770748717
Provider Name (Legal Business Name): DEREK SCOTT GASPER D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GLENDALE BLVD STE 102A
VALPARAISO IN
46383-3767
US

IV. Provider business mailing address

1101 GLENDALE BLVD SUITE 103
VALPARAISO IN
46383-3767
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-9521
  • Fax: 219-465-1442
Mailing address:
  • Phone: 219-464-9521
  • Fax: 219-465-1442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number36.126288
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125054141
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02003800A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: