Basic Information
| Provider Information | |||||||||
| NPI: | 1124029707 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANTOOTH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1072 X RAY DR STE B | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280547488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046711094 | ||||||||
| FaxNumber: | 7046711095 | ||||||||
| Practice Location | |||||||||
| Address1: | 5815 BLAKENEY PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282775732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045422220 | ||||||||
| FaxNumber: | 7045423304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 06/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 200101091 | NC | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8912965 | 05 | NC | MEDICAID |