Provider Demographics
NPI:1649253949
Name:GATLIN, DEIDRA MCCANTS (MD)
Entity type:Individual
Prefix:DR
First Name:DEIDRA
Middle Name:MCCANTS
Last Name:GATLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEIDRA
Other - Middle Name:DAYOKA
Other - Last Name:MCCANTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 470408
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28247-0408
Mailing Address - Country:US
Mailing Address - Phone:704-375-0100
Mailing Address - Fax:704-335-3592
Practice Address - Street 1:7845 LITTLE AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8198
Practice Address - Country:US
Practice Address - Phone:704-375-0100
Practice Address - Fax:704-335-3592
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200600998207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905339Medicaid
NC5905339Medicaid