Basic Information
| Provider Information | |||||||||
| NPI: | 1740261650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHICO | ||||||||
| FirstName: | GAVIN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53032 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711353032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189322081 | ||||||||
| FaxNumber: | 3189322215 | ||||||||
| Practice Location | |||||||||
| Address1: | 1633 MARVEL ST | ||||||||
| Address2: | |||||||||
| City: | COUSHATTA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 710199022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3189322081 | ||||||||
| FaxNumber: | 3189322215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 11956R | LA | N | Other Service Providers | Specialist | 207P00000X | 11956R | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 11956R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00814514 | 01 | LA | RR MEDICARE NUMBER | OTHER | 1699799 | 05 | LA | MEDICAID |