Healthcare Provider Details

I. General information

NPI: 1134326564
Provider Name (Legal Business Name): GARY LYNN GASTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E BOONE ST
TAHLEQUAH OK
74464-3338
US

IV. Provider business mailing address

1310 E BOONE ST
TAHLEQUAH OK
74464-3338
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-7700
  • Fax:
Mailing address:
  • Phone: 918-456-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12817
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier110101250A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: