Provider Demographics
NPI:1134326564
Name:GASTON, GARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LYNN
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 1:1310 E BOONE ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3338
Mailing Address - Country:US
Mailing Address - Phone:918-456-7700
Mailing Address - Fax:
Practice Address - Street 1:1310 E BOONE ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3338
Practice Address - Country:US
Practice Address - Phone:918-456-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12817208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK110101250AMedicaid