Provider Demographics
NPI:1679568992
Name:GASTONIA PEDIATRIC ASSOCIATES, PA
Entity type:Organization
Organization Name:GASTONIA PEDIATRIC ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WATTS,III
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-864-2685
Mailing Address - Street 1:1839 E GARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4839
Mailing Address - Country:US
Mailing Address - Phone:704-864-2685
Mailing Address - Fax:704-864-9363
Practice Address - Street 1:1839 E GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4839
Practice Address - Country:US
Practice Address - Phone:704-864-2685
Practice Address - Fax:704-864-9363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901611Medicaid