Provider Demographics
NPI:1366433773
Name:GASTON MEDICAL ASSOCIATES, PA
Entity type:Organization
Organization Name:GASTON MEDICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUFOLARIN
Authorized Official - Middle Name:AKANFE
Authorized Official - Last Name:AJAO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-861-9030
Mailing Address - Street 1:2664 COURT DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-1449
Mailing Address - Country:US
Mailing Address - Phone:704-861-9030
Mailing Address - Fax:704-833-1234
Practice Address - Street 1:2664 COURT DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1449
Practice Address - Country:US
Practice Address - Phone:704-861-9030
Practice Address - Fax:704-833-1234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9600912207RG0100X
NC201734363L00000X
NC0010-01441363A00000X
NC9501167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011FHMedicaid
NC89011FHMedicaid