Basic Information
| Provider Information | |||||||||
| NPI: | 1902814783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUVIN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1206 | ||||||||
| Address2: | |||||||||
| City: | GOLETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931161206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059643838 | ||||||||
| FaxNumber: | 8056833400 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 W PUEBLO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931054353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055697316 | ||||||||
| FaxNumber: | 8055697317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | A99759 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1902814783 | 05 | CA | MEDICAID |