Healthcare Provider Details

I. General information

NPI: 1821446501
Provider Name (Legal Business Name): DEREK LAWRENCE GAVIN AU.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13015 SUMMERFIELD SQUARE DR
RIVERVIEW FL
33578-7402
US

IV. Provider business mailing address

13015 SUMMERFIELD SQUARE DR
RIVERVIEW FL
33578-7402
US

V. Phone/Fax

Practice location:
  • Phone: 813-879-8045
  • Fax:
Mailing address:
  • Phone: 813-879-8045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY 2034
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: