Basic Information
| Provider Information | |||||||||
| NPI: | 1679550966 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVIGAN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602297 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103628765 | ||||||||
| FaxNumber: | 9103629123 | ||||||||
| Practice Location | |||||||||
| Address1: | 1606 PHYSICIANS DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103628765 | ||||||||
| FaxNumber: | 9103629123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 05/02/2013 | ||||||||
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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 | 208800000X | 17627 | NC | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 3545214001 | 01 | CIGNA | OTHER | 8934985 | 05 | NC | MEDICAID | 34985 | 01 | BLUE CROSS | OTHER |