Provider Demographics
NPI:1881784528
Name:GAVIN, MARY L (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:GAVIN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:3855 WEST CHESTER PIKE, SUITE 280
Practice Address - Street 2:NEMOURS DUPONT PEDIATRICS, NEWTON SQUARE
Practice Address - City:NEWTON SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-2304
Practice Address - Country:US
Practice Address - Phone:610-557-4800
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-10-03
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Provider Licenses
StateLicense IDTaxonomies
DEC10006711208000000X
PAMD418266208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ36790Medicaid
MD4053079Medicaid
PA101018361Medicaid
PA101018361Medicaid
F63030Medicare UPIN