Provider Demographics
NPI:1164955621
Name:MAURER, GAVIN J (MD)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:J
Last Name:MAURER
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 1:1115 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1013
Mailing Address - Country:US
Mailing Address - Phone:605-575-1644
Mailing Address - Fax:
Practice Address - Street 1:1100 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:REDWOOD FALLS
Practice Address - State:MN
Practice Address - Zip Code:56283-2247
Practice Address - Country:US
Practice Address - Phone:507-637-2985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN65109207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program