Provider Demographics
NPI:1467741686
Name:GAVIN, MICHAEL JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:GAVIN
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 278980
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-758-0800
Mailing Address - Fax:585-381-1577
Practice Address - Street 1:167 SULLYS TRL
Practice Address - Street 2:STE 100
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-4567
Practice Address - Country:US
Practice Address - Phone:585-758-0800
Practice Address - Fax:585-381-1577
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2017-04-17
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Provider Licenses
StateLicense IDTaxonomies
NY273591207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04186398Medicaid
NY04186398Medicaid