Provider Demographics
NPI:1235106808
Name:GAVINO, GWENDOLYN G (MD)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:G
Last Name:GAVINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWENDOLYN
Other - Middle Name:Y
Other - Last Name:GATMAITAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7203 W DESCHUTES AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7777
Mailing Address - Country:US
Mailing Address - Phone:509-737-1880
Mailing Address - Fax:509-737-1879
Practice Address - Street 1:7211 W DESCHUTES AVE
Practice Address - Street 2:STE. E
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7728
Practice Address - Country:US
Practice Address - Phone:509-735-9239
Practice Address - Fax:509-735-9310
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052069208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000971022AMedicaid
GA000971022BMedicaid