Provider Demographics
NPI:1922038157
Name:GISLASON, GARDAR (MD)
Entity Type:Individual
Prefix:DR
First Name:GARDAR
Middle Name:
Last Name:GISLASON
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 1:3800 VENETIAN WAY
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8257
Mailing Address - Country:US
Mailing Address - Phone:812-477-6103
Mailing Address - Fax:812-477-4897
Practice Address - Street 1:3800 VENETIAN WAY
Practice Address - Street 2:STE 200
Practice Address - City:NEWBURGH
Practice Address - State:IN
Practice Address - Zip Code:47630-8257
Practice Address - Country:US
Practice Address - Phone:812-477-6103
Practice Address - Fax:812-477-4897
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048640207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200172770AMedicaid
IN351870Medicare ID - Type Unspecified
IN200172770AMedicaid