Basic Information
| Provider Information | |||||||||
| NPI: | 1255365391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAVIN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 DR MARTIN LUTHER KING JR AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724755 | ||||||||
| FaxNumber: | 5052726839 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 DR MARTIN LUTHER KING JR AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052724755 | ||||||||
| FaxNumber: | 5052726839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 93-60 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 4456 | 05 | NM | MEDICAID |