Provider Demographics
NPI:1750656534
Name:CHARLES J GAVIN MD INC.
Entity Type:Organization
Organization Name:CHARLES J GAVIN MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-435-5263
Mailing Address - Street 1:6327 N FRESNO ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5236
Mailing Address - Country:US
Mailing Address - Phone:559-435-5263
Mailing Address - Fax:559-435-7195
Practice Address - Street 1:6327 N FRESNO ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5236
Practice Address - Country:US
Practice Address - Phone:559-435-5263
Practice Address - Fax:559-435-7195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32896174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45334Medicare UPIN