Provider Demographics
NPI:1760437198
Name:KAVLIE, GAYLORD J (MD)
Entity Type:Individual
Prefix:DR
First Name:GAYLORD
Middle Name:J
Last Name:KAVLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4507
Mailing Address - Country:US
Mailing Address - Phone:701-530-6000
Mailing Address - Fax:701-530-6430
Practice Address - Street 1:401 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4507
Practice Address - Country:US
Practice Address - Phone:701-530-6000
Practice Address - Fax:701-530-6430
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4593208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14680Medicaid
ND020018423OtherMEDICARE RAILROAD
NDN2080Medicare PIN
ND14680Medicaid