Provider Demographics
NPI:1922087964
Name:GAVIN, TODD J (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:J
Last Name:GAVIN
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 1:23886 STATE HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001
Mailing Address - Country:US
Mailing Address - Phone:507-625-1424
Mailing Address - Fax:
Practice Address - Street 1:23886 STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7546
Practice Address - Country:US
Practice Address - Phone:507-625-1424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-10
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35388207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNA2951011001OtherPREFERRED ONE
41084933956001C043OtherCHAMPUS
MN970917OtherAMERICAS PPO
MN115539OtherUCARE
MN1M469GAOtherBCBS
MNHP25582OtherHEALTH PARTNERS
MN0802344OtherMEDICA
180021519OtherRR MEDICARE
MN676207700Medicaid
IA937847Medicaid
IA937847Medicaid
MNHP25582OtherHEALTH PARTNERS