Individual
BART WAYNE GASTWIRTH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.P.M.
Contact information
Practice address
1802 S MATTIS AVE, CHAMPAIGN, IL 61821-5923
(217) 383-3260
(217) 383-4459
Mailing address
611 W PARK ST, BWPC, URBANA, IL 61801-2529
(217) 383-6941
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
016-0002956
IL
213EP1101X
Primary Podiatric Medicine Podiatrist
016-002956
IL
213ER0200X
Radiology Podiatrist
016-002956
IL
213ES0000X
Sports Medicine Podiatrist
016-0002956
IL
213ES0131X
Foot Surgery Podiatrist
Primary
016-002956
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
60001121
BLUE CROSS BLUE SHIELD
IL
Enumeration date
09/30/2005
Last updated
10/18/2016
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