Provider Demographics
NPI:1740261650
Name:CHICO, GAVIN F (M D)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:F
Last Name:CHICO
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 53032
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71135-3032
Mailing Address - Country:US
Mailing Address - Phone:318-932-2081
Mailing Address - Fax:318-932-2215
Practice Address - Street 1:1633 MARVEL ST
Practice Address - Street 2:
Practice Address - City:COUSHATTA
Practice Address - State:LA
Practice Address - Zip Code:71019-9022
Practice Address - Country:US
Practice Address - Phone:318-932-2081
Practice Address - Fax:318-932-2215
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11956R174400000X, 207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP00814514OtherRR MEDICARE NUMBER
LA1699799Medicaid
LA5Y884CP62Medicare PIN
LAG13356Medicare UPIN
LA1699799Medicaid
LA5Y884CP64Medicare PIN
LA5E999CV98Medicare PIN
LA5Y884CP63Medicare PIN
LA5E999Medicare PIN