Provider Demographics
NPI:1073508461
Name:EASTERDAY, GERRY S (MD)
Entity Type:Individual
Prefix:DR
First Name:GERRY
Middle Name:S
Last Name:EASTERDAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3978 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-672-4680
Mailing Address - Fax:260-672-4685
Practice Address - Street 1:3978 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1712
Practice Address - Country:US
Practice Address - Phone:260-672-4680
Practice Address - Fax:260-672-4685
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036101A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND95738Medicare UPIN
IN047840WMedicare ID - Type Unspecified
OH2517931Medicaid
000000004345OtherMPLAN
IN000000082540OtherANTHEM