Healthcare Provider Details

I. General information

NPI: 1881784528
Provider Name (Legal Business Name): MARY L. GAVIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 WEST CHESTER PIKE, SUITE 280 NEMOURS DUPONT PEDIATRICS, NEWTON SQUARE
NEWTON SQUARE PA
19073-2304
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 610-557-4800
  • Fax: 302-651-4945
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC10006711
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD418266
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: