Provider Demographics
NPI:1821073149
Name:GISH, DAVID LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LAWRENCE
Last Name:GISH
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 1:131 MEDICAL PARK RD STE 305
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8525
Mailing Address - Country:US
Mailing Address - Phone:704-663-0006
Mailing Address - Fax:704-663-5224
Practice Address - Street 1:131 MEDICAL PARK RD STE 305
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-663-0006
Practice Address - Fax:704-663-5224
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800872208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891149NMedicaid
1149NOtherBC
1149NOtherBC
NC891149NMedicaid