Provider Demographics
NPI:1215902663
Name:GOURDIN, FREDERICK WALTER (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:WALTER
Last Name:GOURDIN
Suffix:
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 1:78 LONG SHOALS RD
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-7782
Mailing Address - Country:US
Mailing Address - Phone:828-684-0703
Mailing Address - Fax:828-684-5344
Practice Address - Street 1:78 LONG SHOALS RD
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-7782
Practice Address - Country:US
Practice Address - Phone:828-684-0703
Practice Address - Fax:828-684-5344
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800549207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8911375Medicaid
NCB04230Medicare UPIN
NC2255486Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER