1306965389 NPI number — JOHN E. GASTON MD DBA

Table of content: (NPI 1306965389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306965389 NPI number — JOHN E. GASTON MD DBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHN E. GASTON MD DBA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAYETTEVILLE PEDIATRICS
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306965389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2312B MURCHISON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28301-3518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-488-6331
Provider Business Mailing Address Fax Number:
910-488-5351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2312B MURCHISON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28301-3518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-488-6331
Provider Business Practice Location Address Fax Number:
910-488-5351
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GASTON
Authorized Official First Name:
JOHNNY
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
DBA
Authorized Official Telephone Number:
910-488-6331

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  22112 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8934945 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8901585 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com