Provider Demographics
NPI:1669434619
Name:GAVLICK, KIRK MATTHEW (DO)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:MATTHEW
Last Name:GAVLICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 N CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85719-2306
Mailing Address - Country:US
Mailing Address - Phone:520-624-8935
Mailing Address - Fax:520-624-0053
Practice Address - Street 1:445 N SILVERBELL RD
Practice Address - Street 2:STE 200
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-2685
Practice Address - Country:US
Practice Address - Phone:520-624-8935
Practice Address - Fax:520-624-0053
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4071207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ111910Medicare PIN
AZZ111907Medicare PIN
G88224Medicare UPIN