Provider Demographics
NPI:1558582742
Name:GAST, MARY JANE (RD, CDE)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JANE
Last Name:GAST
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 N MERIDIAN ST # 300
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46290-1024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:141 W 22ND ST STE 210
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4389
Practice Address - Country:US
Practice Address - Phone:765-646-8795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000680A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN179230QMedicare ID - Type Unspecified