Provider Demographics
NPI:1053327155
Name:MCCALL, GAVIN W (MPT)
Entity Type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:W
Last Name:MCCALL
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7930 CHESAPEAKE BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-3846
Mailing Address - Country:US
Mailing Address - Phone:757-588-4325
Mailing Address - Fax:757-588-0991
Practice Address - Street 1:7930 CHESAPEAKE BLVD STE F
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-3846
Practice Address - Country:US
Practice Address - Phone:757-588-4325
Practice Address - Fax:757-588-0991
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8920460Medicaid