Basic Information
| Provider Information | |||||||||
| NPI: | 1922075597 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVINO | ||||||||
| FirstName: | ROMAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7211 W DESCHUTES AVE | ||||||||
| Address2: | SUITE E | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097359239 | ||||||||
| FaxNumber: | 5097359310 | ||||||||
| Practice Location | |||||||||
| Address1: | 7211 W DESCHUTES AVE | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097371880 | ||||||||
| FaxNumber: | 5097371879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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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 | 208000000X | 052175 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000975939A | 05 | GA | MEDICAID | 000975939B | 05 | GA | MEDICAID | 1922075597 | 05 | WA | MEDICAID |