Provider Demographics
NPI:1942263843
Name:GASTMAN, IRVIN J (DO, PHD)
Entity Type:Individual
Prefix:DR
First Name:IRVIN
Middle Name:J
Last Name:GASTMAN
Suffix:
Gender:M
Credentials:DO, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25241 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1404
Mailing Address - Country:US
Mailing Address - Phone:313-538-3800
Mailing Address - Fax:313-538-3800
Practice Address - Street 1:25241 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1404
Practice Address - Country:US
Practice Address - Phone:313-538-3800
Practice Address - Fax:313-538-3088
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIIG007321207Q00000X
MI51010073212083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1293005Medicaid
MIE26008Medicare UPIN
MIOF37176008Medicare ID - Type Unspecified