Provider Demographics
NPI:1922075597
Name:GAVINO, ROMAN R (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:R
Last Name:GAVINO
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 1:7211 W DESCHUTES AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7728
Mailing Address - Country:US
Mailing Address - Phone:509-735-9239
Mailing Address - Fax:509-735-9310
Practice Address - Street 1:7211 W DESCHUTES AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7728
Practice Address - Country:US
Practice Address - Phone:509-737-1880
Practice Address - Fax:509-737-1879
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-02
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052175208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000975939AMedicaid
GA000975939BMedicaid
WA1922075597Medicaid