Provider Demographics
NPI:1629382957
Name:KASPER, FRED EUGENE (IDC)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:EUGENE
Last Name:KASPER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3644
Mailing Address - Country:US
Mailing Address - Phone:228-206-4918
Mailing Address - Fax:
Practice Address - Street 1:5501 MARVIN SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9007
Practice Address - Country:US
Practice Address - Phone:228-822-5748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider