Healthcare Provider Details

I. General information

NPI: 1306965389
Provider Name (Legal Business Name): JOHN E. GASTON MD DBA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312B MURCHISON RD
FAYETTEVILLE NC
28301-3518
US

IV. Provider business mailing address

2312B MURCHISON RD
FAYETTEVILLE NC
28301-3518
US

V. Phone/Fax

Practice location:
  • Phone: 910-488-6331
  • Fax: 910-488-5351
Mailing address:
  • Phone: 910-488-6331
  • Fax: 910-488-5351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number22112
License Number StateNC

VIII. Authorized Official

Name: DR. JOHNNY EUGENE GASTON
Title or Position: DBA
Credential: M.D.
Phone: 910-488-6331