Provider Demographics
NPI:1164426847
Name:GASTORF, MELISSA ANN (DO,)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:GASTORF
Suffix:
Gender:F
Credentials:DO,
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:FOSDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:239 EAGLELAKE DR
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-7421
Mailing Address - Country:US
Mailing Address - Phone:580-931-9135
Mailing Address - Fax:580-931-9161
Practice Address - Street 1:1004 N 19TH AVE
Practice Address - Street 2:BUILDING 2
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3016
Practice Address - Country:US
Practice Address - Phone:580-931-9135
Practice Address - Fax:580-931-9161
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069300AMedicaid
OKI39348Medicare UPIN
OK200069300AMedicaid