Healthcare Provider Details

I. General information

NPI: 1891952388
Provider Name (Legal Business Name): BRIAN JOSEPH GAVITT MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9517
  • Fax: 513-558-3136
Mailing address:
  • Phone: 513-585-5506
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberA111684
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number35 129410
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: