Provider Demographics
NPI:1548227804
Name:LEASK, GAVIN M (MD)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:M
Last Name:LEASK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-667-1891
Mailing Address - Fax:843-665-2516
Practice Address - Street 1:101 WILLIAM H. JOHNSON STREET
Practice Address - Street 2:SUITE 600
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2716
Practice Address - Country:US
Practice Address - Phone:843-667-1891
Practice Address - Fax:843-665-2516
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC19828207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890601UMedicaid
SC198280Medicaid
SC198280Medicaid
NC890601UMedicaid