Provider Demographics
NPI:1770748717
Name:GASPER, DEREK SCOTT (DO)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:SCOTT
Last Name:GASPER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 GLENDALE BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3767
Mailing Address - Country:US
Mailing Address - Phone:219-464-9521
Mailing Address - Fax:219-465-1442
Practice Address - Street 1:1101 GLENDALE BLVD STE 102A
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3767
Practice Address - Country:US
Practice Address - Phone:219-464-9521
Practice Address - Fax:219-465-1442
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36.126288207Q00000X
IL125054141390200000X
IN02003800A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program