Healthcare Provider Details

I. General information

NPI: 1528004587
Provider Name (Legal Business Name): TIMOTHY J GAVIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 FRANCE AVE S SUITE W440
EDINA MN
55435-2163
US

IV. Provider business mailing address

3400 W 66TH ST SUITE 350
EDINA MN
55435-2111
US

V. Phone/Fax

Practice location:
  • Phone: 952-927-7004
  • Fax: 952-927-5146
Mailing address:
  • Phone: 952-832-0805
  • Fax: 952-832-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number47505
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number47505
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: