Provider Demographics
NPI:1952348963
Name:GISH, LARRY M (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
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 1:1035 LINCOLNTON RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-6260
Mailing Address - Country:US
Mailing Address - Phone:704-638-9990
Mailing Address - Fax:704-639-0785
Practice Address - Street 1:1035 LINCOLNTON RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-6260
Practice Address - Country:US
Practice Address - Phone:704-638-9990
Practice Address - Fax:704-639-0785
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8935662Medicaid
C84068Medicare UPIN
NC8935662Medicaid