Healthcare Provider Details

I. General information

NPI: 1063539252
Provider Name (Legal Business Name): FRED WAYNE GASKIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 GARRETT ST
FREDERICKTOWN MO
63645-1084
US

IV. Provider business mailing address

402 S SILVER SPRINGS RD
CAPE GIRARDEAU MO
63703-7536
US

V. Phone/Fax

Practice location:
  • Phone: 573-334-1100
  • Fax: 573-651-4345
Mailing address:
  • Phone: 573-334-1100
  • Fax: 573-651-4345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34748
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: