MEDICARE: DR. EDISON GENARO GAVILANES MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	257788	NY
2	390200000X	Student in an Organized Health Care Education/Training Program
3	207RP1001X	Pulmonary Disease Physician	257788	NY

General Provider Information

NPI Number	:	1992967731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDISON GENARO GAVILANES MD

Provider Business Mailing Address
First Line	:	56-45 MAIN STREET
Second Line	:
City	:	FLUSHING
State	:	NY
Zip	:	11355
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	317 BROADWAY STE A
Second Line	:
City	:	AMITYVILLE
State	:	NY
Zip	:	11701-2770
Country	:	US
Telephone Number	:	631-598-5864
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	04/05/2020

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