1073833612 NPI number — DR. GEORGE JEFFREY GAVERN D.O.

Table of content: DR. GEORGE JEFFREY GAVERN D.O. (NPI 1073833612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073833612 NPI number — DR. GEORGE JEFFREY GAVERN D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAVERN
Provider First Name:
GEORGE
Provider Middle Name:
JEFFREY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073833612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NVRA BUSINESS OFFICE
Provider Second Line Business Mailing Address:
385 MAIN ST SOUTH
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-264-7999
Provider Business Mailing Address Fax Number:
203-264-7477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NVRA BUSINESS OFFICE
Provider Second Line Business Practice Location Address:
385 MAIN ST SOUTH
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-264-7999
Provider Business Practice Location Address Fax Number:
203-264-7477
Provider Enumeration Date:
06/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  054089 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D400227516 . This is a "DIS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D400227523 . This is a "PDI" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D400227521 . This is a "NVRA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D400227511 . This is a "MRI" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: D400227517 . This is a "DIA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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