Provider Demographics
NPI:1083623979
Name:GASTON, LARRY H (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:H
Last Name:GASTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2300 GARRISON BLVD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2335
Mailing Address - Country:US
Mailing Address - Phone:410-945-7544
Mailing Address - Fax:410-945-3605
Practice Address - Street 1:2300 GARRISON BLVD
Practice Address - Street 2:SUITE 260
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216-2335
Practice Address - Country:US
Practice Address - Phone:410-945-7544
Practice Address - Fax:410-945-3605
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD29768207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD331621100Medicaid
MD3316Medicare ID - Type Unspecified
MDC44505Medicare UPIN