Provider Demographics
NPI:1952394108
Name:GASQUE, BOYD BENNETT JR (MD)
Entity type:Individual
Prefix:
First Name:BOYD
Middle Name:BENNETT
Last Name:GASQUE
Suffix:JR
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:P.O. BOX 1527
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1527
Mailing Address - Country:US
Mailing Address - Phone:910-738-8222
Mailing Address - Fax:910-671-0846
Practice Address - Street 1:209 WEST 27TH STREET
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3016
Practice Address - Country:US
Practice Address - Phone:910-738-8222
Practice Address - Fax:910-671-0846
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0000217792085R0202X
NC217792085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8934956Medicaid
NC34956OtherBLUE CROSS BLUE SHIELD
C82437Medicare UPIN
NC8934956Medicaid