Provider Demographics
NPI:1669434379
Name:HETHCOAT, GAYLAND OLIVER (MD)
Entity type:Individual
Prefix:
First Name:GAYLAND
Middle Name:OLIVER
Last Name:HETHCOAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:190 CAMPUS BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2872
Mailing Address - Country:US
Mailing Address - Phone:540-662-6135
Mailing Address - Fax:540-662-5845
Practice Address - Street 1:190 CAMPUS BLVD
Practice Address - Street 2:STE 200
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2872
Practice Address - Country:US
Practice Address - Phone:540-662-6135
Practice Address - Fax:540-662-5845
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101231968207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000875693OtherWV BLUE SHIELD
WV3810003817OtherWV MEDICAID GROUP
C00085OtherVA MEDICARE B
53556OtherSENTARA PROFESSIONAL
001717444OtherWV BLUE SHIELD
219651OtherANTHEM PROFESSIONAL
VA005873959Medicaid
WV2001954000Medicaid
2119638OtherMAMSI PROFESSIONAL
G29615Medicare UPIN
001717444OtherWV BLUE SHIELD