Healthcare Provider Details

I. General information

NPI: 1861479529
Provider Name (Legal Business Name): AVIT JOHN GREMILLION III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: FRERE GREMILLION MD

II. Dates (important events)

Enumeration Date: 12/23/2005
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 TOMMY MUNRO DR STE E
BILOXI MS
39532-2139
US

IV. Provider business mailing address

962 TOMMY MUNRO DR STE E
BILOXI MS
39532-2139
US

V. Phone/Fax

Practice location:
  • Phone: 228-388-7000
  • Fax: 833-849-9899
Mailing address:
  • Phone: 228-388-7000
  • Fax: 833-849-9899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number023984
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number023984
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number17239
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number17239
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: