Basic Information
Provider Information | |||||||||
NPI: | 1821408444 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GULVIN | ||||||||
FirstName: | JOSHUA | ||||||||
MiddleName: | MICHAEL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GULVIN | ||||||||
OtherFirstName: | JOSHUA | ||||||||
OtherMiddleName: | MICHAEL | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 2500 NE NEFF RD | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977016015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413824321 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2500 NE NEFF RD | ||||||||
Address2: |   | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977016015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413824321 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/05/2014 | ||||||||
LastUpdateDate: | 10/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | R3095 | TX | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD198491 | OR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8JM173 | 01 | TX | BCBS | OTHER | 385544701 | 05 | TX |   | MEDICAID | 385544702 | 05 | TX |   | MEDICAID |