Basic Information
| Provider Information | |||||||||
| NPI: | 1881719615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVLAK | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DRIVE | ||||||||
| Address2: | SUITE 1200 WEST TOWER | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002323550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4600 S PARK AVENUE | ||||||||
| Address2: | SUITE 3-5 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157784066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 01/08/2010 | ||||||||
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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 | 2083X0100X | 13554 | AZ | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine |
ID Information
| ID | Type | State | Issuer | Description | 282137 | 05 | AZ | MEDICAID | 300205 | 05 | AZ | MEDICAID |