Provider Demographics
NPI:1043269129
Name:GRAVATTE, LEROY T IV (MD)
Entity Type:Individual
Prefix:
First Name:LEROY
Middle Name:T
Last Name:GRAVATTE
Suffix:IV
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:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4916 PLANK RD
Practice Address - Street 2:
Practice Address - City:NORTH GARDEN
Practice Address - State:VA
Practice Address - Zip Code:22959-1613
Practice Address - Country:US
Practice Address - Phone:434-243-4660
Practice Address - Fax:434-244-9476
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101042101207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10035490Medicaid
VA10035490Medicaid
VA014024C49Medicare PIN
VA1003853920Medicare UPIN
VA1003853920Medicare PIN