Provider Demographics
NPI:1073833612
Name:GAVERN, GEORGE JEFFREY (DO)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:JEFFREY
Last Name:GAVERN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NVRA BUSINESS OFFICE
Mailing Address - Street 2:385 MAIN ST SOUTH
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488
Mailing Address - Country:US
Mailing Address - Phone:203-264-7999
Mailing Address - Fax:203-264-7477
Practice Address - Street 1:NVRA BUSINESS OFFICE
Practice Address - Street 2:385 MAIN ST SOUTH
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488
Practice Address - Country:US
Practice Address - Phone:203-264-7999
Practice Address - Fax:203-264-7477
Is Sole Proprietor?:No
Enumeration Date:2010-06-05
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0540892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400227516OtherDIS
CTD400227523OtherPDI
CTD400227521OtherNVRA
CTD400227511OtherMRI
CTD400227517OtherDIA