Provider Demographics
NPI:1578597571
Name:GAVINO, WAYNE R (MD)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:R
Last Name:GAVINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:860 SUMMIT ST
Mailing Address - Street 2:SUITE 254
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60120-4339
Mailing Address - Country:US
Mailing Address - Phone:847-695-8721
Mailing Address - Fax:847-695-8755
Practice Address - Street 1:860 SUMMIT ST
Practice Address - Street 2:SUITE 254
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4339
Practice Address - Country:US
Practice Address - Phone:847-695-8721
Practice Address - Fax:847-695-8755
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL36538912084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3653891OtherSTATE LICENSE
C42489Medicare UPIN
IL3653891OtherSTATE LICENSE