Provider Demographics
NPI:1558063123
Name:SMITH, GAVIN IZAAK
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:IZAAK
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64500 STATE ROUTE 56
Mailing Address - Street 2:
Mailing Address - City:CREOLA
Mailing Address - State:OH
Mailing Address - Zip Code:45622-9006
Mailing Address - Country:US
Mailing Address - Phone:740-248-8172
Mailing Address - Fax:
Practice Address - Street 1:64500 STATE ROUTE 56
Practice Address - Street 2:
Practice Address - City:CREOLA
Practice Address - State:OH
Practice Address - Zip Code:45622-9006
Practice Address - Country:US
Practice Address - Phone:740-248-8172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant