Healthcare Provider Details

I. General information

NPI: 1255682936
Provider Name (Legal Business Name): EVANGELOS P GAVATHAS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 09/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6825 SW 87TH AVE
MIAMI FL
33173-2502
US

IV. Provider business mailing address

PO BOX 266173
WESTON FL
33326-6173
US

V. Phone/Fax

Practice location:
  • Phone: 786-466-7201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0205X
TaxonomyRadiological Physics Physician
License NumberTRP-366
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: