Healthcare Provider Details

I. General information

NPI: 1063667020
Provider Name (Legal Business Name): CAROLINA GASTROENTEROLOGY SPECIALISTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 AIRPORT BLVD NW STE F
WILSON NC
27896-8674
US

IV. Provider business mailing address

3520 AIRPORT BLVD NW STE F
WILSON NC
27896-8674
US

V. Phone/Fax

Practice location:
  • Phone: 252-206-5622
  • Fax: 252-206-5623
Mailing address:
  • Phone: 252-206-5622
  • Fax: 252-206-5623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License NumberAS0112
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: VENKATESH LAKSHMAN
Title or Position: OWNER MEDICAL DIRECTOR
Credential:
Phone: 252-206-5622