MEDICARE: DR. GAVIN F CHICO M. D.

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
1	174400000X	Specialist	11956R	LA
2	207P00000X	Emergency Medicine Physician	11956R	LA
3	207R00000X	Internal Medicine Physician	11956R	LA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00814514	OTHER	LA	RR MEDICARE NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740261650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GAVIN F CHICO M. D.

Provider Business Mailing Address
First Line	:	PO BOX 53032
Second Line	:
City	:	SHREVEPORT
State	:	LA
Zip	:	71135-3032
Country	:	US
Telephone Number	:	318-932-2081
Fax Number	:	318-932-2215

Provider Business Practice Location Address
First Line	:	1633 MARVEL ST
Second Line	:
City	:	COUSHATTA
State	:	LA
Zip	:	71019-9022
Country	:	US
Telephone Number	:	318-932-2081
Fax Number	:	318-932-2215

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	03/17/2021

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Directions to “ DR. GAVIN F CHICO M. D.” Practice Location

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