Provider Demographics
NPI:1821089392
Name:GAVENCAK, JOHN RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RICHARD
Last Name:GAVENCAK
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 1:400 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11518-1433
Mailing Address - Country:US
Mailing Address - Phone:516-599-2732
Mailing Address - Fax:516-593-2075
Practice Address - Street 1:400 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:EAST ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11518-1433
Practice Address - Country:US
Practice Address - Phone:516-599-2732
Practice Address - Fax:516-593-2075
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124874207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY330821Medicare ID - Type Unspecified
B13164Medicare UPIN