Provider Demographics
NPI:1225011596
Name:GAVAGAN, ANDREW K (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:K
Last Name:GAVAGAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1080 KIRTS BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4881
Mailing Address - Country:US
Mailing Address - Phone:248-369-9300
Mailing Address - Fax:248-362-5272
Practice Address - Street 1:1080 KIRTS BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4881
Practice Address - Country:US
Practice Address - Phone:248-369-9300
Practice Address - Fax:248-362-5272
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2014-08-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301057593208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI349596810Medicaid
MI349596810Medicaid
OM65780Medicare ID - Type Unspecified