Healthcare Provider Details

I. General information

NPI: 1073833612
Provider Name (Legal Business Name): GEORGE JEFFREY GAVERN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2010
Last Update Date: 07/13/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NVRA BUSINESS OFFICE 385 MAIN ST SOUTH
SOUTHBURY CT
06488
US

IV. Provider business mailing address

NVRA BUSINESS OFFICE 385 MAIN ST SOUTH
SOUTHBURY CT
06488
US

V. Phone/Fax

Practice location:
  • Phone: 203-264-7999
  • Fax: 203-264-7477
Mailing address:
  • Phone: 203-264-7999
  • Fax: 203-264-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number054089
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: