Provider Demographics
NPI:1033148226
Name:FODERINGHAM, GASTON G (MD)
Entity Type:Individual
Prefix:
First Name:GASTON
Middle Name:G
Last Name:FODERINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636019
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 GROSS CRESCENT CIR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3643
Practice Address - Country:US
Practice Address - Phone:706-858-2000
Practice Address - Fax:865-291-3228
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052514207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00255604OtherRAILROAD MEDICARE
GAP00255604OtherRAILROAD MEDICARE
GA93BBKHKMedicare PIN