Provider Demographics
NPI:1720167893
Name:GAVIN, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79563 ALBERT THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:LA
Mailing Address - Zip Code:70437-7539
Mailing Address - Country:US
Mailing Address - Phone:225-755-1400
Mailing Address - Fax:225-755-1555
Practice Address - Street 1:13702 COURSEY BLVD
Practice Address - Street 2:BUILDING 10 SUITE B
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70817-1370
Practice Address - Country:US
Practice Address - Phone:225-755-1400
Practice Address - Fax:225-755-1555
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.014641207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAB74911Medicare UPIN
LA5R215Medicare ID - Type Unspecified