Provider Demographics
NPI:1154305498
Name:GAVAZOV, MIROSLAV (MD)
Entity Type:Individual
Prefix:
First Name:MIROSLAV
Middle Name:
Last Name:GAVAZOV
Suffix:
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 1:316 ASHLEY FOREST DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-5411
Mailing Address - Country:US
Mailing Address - Phone:919-933-6285
Mailing Address - Fax:
Practice Address - Street 1:861 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4728
Practice Address - Country:US
Practice Address - Phone:919-934-0985
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700253207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891082GMedicaid
NCH09906Medicare UPIN
NC2023478Medicare ID - Type Unspecified