Healthcare Provider Details

I. General information

NPI: 1083623979
Provider Name (Legal Business Name): LARRY H GASTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 GARRISON BLVD SUITE 260
BALTIMORE MD
21216-2335
US

IV. Provider business mailing address

2300 GARRISON BLVD SUITE 260
BALTIMORE MD
21216-2335
US

V. Phone/Fax

Practice location:
  • Phone: 410-945-7544
  • Fax: 410-945-3605
Mailing address:
  • Phone: 410-945-7544
  • Fax: 410-945-3605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD29768
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: