Provider Demographics
NPI:1881719615
Name:GAVLAK, ROBERT N (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:N
Last Name:GAVLAK
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 1:5080 SPECTRUM DRIVE
Mailing Address - Street 2:SUITE 1200 WEST TOWER
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001
Mailing Address - Country:US
Mailing Address - Phone:800-232-3550
Mailing Address - Fax:
Practice Address - Street 1:4600 S PARK AVENUE
Practice Address - Street 2:SUITE 3-5
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85714
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ135542083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ282137Medicaid
AZ300205Medicaid
AZZ133666Medicare UPIN
AZZ133665Medicare UPIN
AZZ120952Medicare PIN
AZ282137Medicaid
AZ300205Medicaid