Provider Demographics
NPI:1124029707
Name:MANTOOTH, GREGORY ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:MANTOOTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1072 X RAY DR STE B
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-671-1094
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:5815 BLAKENEY PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-5732
Practice Address - Country:US
Practice Address - Phone:704-542-2220
Practice Address - Fax:704-542-3304
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-06-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC200101091208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912965Medicaid
NC2289760Medicare PIN
NCH45335Medicare UPIN