Basic Information
| Provider Information | |||||||||
| NPI: | 1376631168 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTON NEUROLOGICAL, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GASTON NEUROLOGICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048651700 | ||||||||
| FaxNumber: | 7048657948 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048651700 | ||||||||
| FaxNumber: | 7048657948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIFINI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7048651700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 200001228722 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 89012XJ | 05 | NC | MEDICAID |