Provider Demographics
NPI:1962629493
Name:GASTON DIGESTIVE DISEASE CLINIC, P.A.
Entity Type:Organization
Organization Name:GASTON DIGESTIVE DISEASE CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:I
Authorized Official - Credentials:MD
Authorized Official - Phone:704-867-3585
Mailing Address - Street 1:2550 COURT DR STE 201
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2152
Mailing Address - Country:US
Mailing Address - Phone:704-867-3585
Mailing Address - Fax:704-861-1779
Practice Address - Street 1:2550 COURT DR STE 201
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2152
Practice Address - Country:US
Practice Address - Phone:704-867-3585
Practice Address - Fax:704-861-1779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23513174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty