Healthcare Provider Details

I. General information

NPI: 1821089392
Provider Name (Legal Business Name): JOHN RICHARD GAVENCAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 ATLANTIC AVE
EAST ROCKAWAY NY
11518-1433
US

IV. Provider business mailing address

400 ATLANTIC AVE
EAST ROCKAWAY NY
11518-1433
US

V. Phone/Fax

Practice location:
  • Phone: 516-599-2732
  • Fax: 516-593-2075
Mailing address:
  • Phone: 516-599-2732
  • Fax: 516-593-2075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number124874
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: