Provider Demographics
NPI:1972790848
Name:GASIEWICZ, WALLACE JOHN (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:JOHN
Last Name:GASIEWICZ
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 1:10832 WEATHERLY CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-8857
Mailing Address - Country:US
Mailing Address - Phone:317-823-9380
Mailing Address - Fax:
Practice Address - Street 1:10832 WEATHERLY CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-8857
Practice Address - Country:US
Practice Address - Phone:317-823-9380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059216A2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F10601Medicare UPIN