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NPI Code Detail

MEDICARE: GAVIN KOLODGE

MEDICARE: GAVIN KOLODGE
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12081P2900XPain Medicine (Physical Medicine & Rehabilitation) Physician20A18281CA

General Provider Information

NPI Number : 1407210537
Entity Type Code : Individual
Provider Name (Legal Business Name) : GAVIN KOLODGE
Provider Business Mailing Address
First Line : 9095 RIO SAN DIEGO DR STE 410
Second Line :
City : SAN DIEGO
State : CA
Zip : 92108-1679
Country : US
Telephone Number : 858-357-9450
Fax Number : 858-412-6376
Provider Business Practice Location Address
First Line : 9095 RIO SAN DIEGO DR STE 450
Second Line :
City : SAN DIEGO
State : CA
Zip : 92108-1726
Country : US
Telephone Number : 619-853-8860
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/05/2016
Last Update Date : 01/12/2026

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Directions to “ GAVIN KOLODGE ” Practice Location

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