Provider Demographics
NPI:1073594784
Name:MAESAKA, GERALD N (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:N
Last Name:MAESAKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 STADIUM MALL DR
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47907-2052
Mailing Address - Country:US
Mailing Address - Phone:765-494-1700
Mailing Address - Fax:765-496-1227
Practice Address - Street 1:601 STADIUM MALL DR
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47907-2052
Practice Address - Country:US
Practice Address - Phone:765-494-1700
Practice Address - Fax:765-496-1227
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044360207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200148130Medicaid
IN200148130Medicaid