Provider Demographics
NPI:1235662487
Name:GAVILAN YODU, RONALD (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:GAVILAN YODU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RONALD
Other - Middle Name:
Other - Last Name:GAVILAN YODU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4205 BELFORT RD STE 4015
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-3623
Mailing Address - Country:US
Mailing Address - Phone:904-450-6063
Mailing Address - Fax:904-539-4091
Practice Address - Street 1:36500 EMERALD COAST PKWY
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-4713
Practice Address - Country:US
Practice Address - Phone:850-837-0032
Practice Address - Fax:850-837-9257
Is Sole Proprietor?:No
Enumeration Date:2017-04-05
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME150508207Q00000X
390200000X
CAA164003207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program