Provider Demographics
NPI:1124118971
Name:GASTINEAU, JERRY L
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:L
Last Name:GASTINEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 W ELK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2848
Mailing Address - Country:US
Mailing Address - Phone:423-543-1261
Mailing Address - Fax:423-543-7500
Practice Address - Street 1:1505 W ELK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2848
Practice Address - Country:US
Practice Address - Phone:423-543-1261
Practice Address - Fax:423-543-7500
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD7688170100000X
TN7688207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN201575OtherBLUECARE
TN3152032Medicaid
TNBLUECROSSOther201575
TNTN0102OtherAMERICHOICE
TNTN0102OtherJOHNDEERE
TN4360576OtherBCBS
TNBO2385Medicare UPIN
TNTN0102OtherAMERICHOICE
TN3152032Medicaid