Healthcare Provider Details

I. General information

NPI: 1679568992
Provider Name (Legal Business Name): GASTONIA PEDIATRIC ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 E GARRISON BLVD
GASTONIA NC
28054-4839
US

IV. Provider business mailing address

1839 E GARRISON BLVD
GASTONIA NC
28054-4839
US

V. Phone/Fax

Practice location:
  • Phone: 704-864-2685
  • Fax: 704-864-9363
Mailing address:
  • Phone: 704-864-2685
  • Fax: 704-864-9363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN C WATTS,III
Title or Position: VICE PRESIDENT
Credential: M.D.
Phone: 704-864-2685