Provider Demographics
NPI:1114580107
Name:GAVIN, THOMAS (CO/LO)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:
Last Name:GAVIN
Suffix:
Gender:M
Credentials:CO/LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 JORIE BLVD STE 24
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-4450
Mailing Address - Country:US
Mailing Address - Phone:630-573-7777
Mailing Address - Fax:630-573-4424
Practice Address - Street 1:1010 JORIE BLVD STE 24
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-4450
Practice Address - Country:US
Practice Address - Phone:630-573-7777
Practice Address - Fax:630-573-4424
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE