Provider Demographics
NPI:1457323206
Name:GAVILANEZ, MARCELO R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCELO
Middle Name:R
Last Name:GAVILANEZ
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 1:100 W HORTON ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-3607
Mailing Address - Country:US
Mailing Address - Phone:260-824-0800
Mailing Address - Fax:260-824-7243
Practice Address - Street 1:100 W HORTON ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-3607
Practice Address - Country:US
Practice Address - Phone:260-824-0800
Practice Address - Fax:260-824-7243
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030096A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100257780Medicaid
IN234760SMedicare PIN
INB29756Medicare UPIN
IN100257780Medicaid
IN371310CMedicare ID - Type Unspecified
IN370640CMedicare ID - Type Unspecified