Provider Demographics
NPI:1033347075
Name:GASTON, RICHARD LARRY (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LARRY
Last Name:GASTON
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-301-8074
Mailing Address - Fax:859-301-4945
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-8074
Practice Address - Fax:859-301-4945
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY485022083A0300X, 208M00000X
IA40922207Q00000X, 208M00000X
IL036133303208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201358060Medicaid
KY7100385920Medicaid
OH0144763Medicaid
KYK173390Medicare PIN