Provider Demographics
NPI:1710961263
Name:GASTON DERMATOLOGY CLINIC P.A.
Entity Type:Organization
Organization Name:GASTON DERMATOLOGY CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-864-8386
Mailing Address - Street 1:1072 X RAY DR
Mailing Address - Street 2:P.O. BOX 3598
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:704-864-8386
Mailing Address - Fax:704-864-3361
Practice Address - Street 1:1072 X RAY DR
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7488
Practice Address - Country:US
Practice Address - Phone:704-864-8386
Practice Address - Fax:704-864-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39982207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8947774Medicaid
NC8947774Medicaid