Provider Demographics
NPI:1801152517
Name:GASTALA, JOSEPH BRIAN (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:BRIAN
Last Name:GASTALA
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 1:1478 S PRAIRIE AVE UNIT N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3345
Mailing Address - Country:US
Mailing Address - Phone:708-642-6188
Mailing Address - Fax:
Practice Address - Street 1:1325 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1449
Practice Address - Country:US
Practice Address - Phone:630-859-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125061502207R00000X
IAR-98732085R0202X
IAMD-443762085R0202X
390200000X
IL036.1453712085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program