Provider Demographics
NPI:1063519445
Name:GANTT, PICKENS A II (MD)
Entity type:Individual
Prefix:
First Name:PICKENS
Middle Name:A
Last Name:GANTT
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302
Mailing Address - Country:US
Mailing Address - Phone:304-388-2863
Mailing Address - Fax:304-388-2866
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-388-2863
Practice Address - Fax:304-388-2866
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN13100174400000X
WV22945207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010685Medicaid
GN4224353Medicare PIN