Provider Demographics
NPI:1073990644
Name:GASTON, CHARLES V JR (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:V
Last Name:GASTON
Suffix:JR
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 746450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6450
Mailing Address - Country:US
Mailing Address - Phone:866-401-3057
Mailing Address - Fax:318-868-6430
Practice Address - Street 1:1601 CENTER ST
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-1541
Practice Address - Country:US
Practice Address - Phone:251-471-7008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-02
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1445252085R0202X, 2085R0204X
390200000X
ALMD.485662085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLJ1C2OtherBCBS
FLNW171OtherMEDICARE
FL1114401-00Medicaid
FLNW170OtherMEDICARE