=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962432625
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GASTORF FAMILY CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1004 N 19TH AVE BLDG 2
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74701-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-931-9135
-----------------------------------------------------
Fax | 580-931-9161
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1004 N 19TH AVE BLDG 2
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74701-3017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-931-9135
-----------------------------------------------------
Fax | 580-931-9161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELISSA GASTORF
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 580-931-9135
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------