Basic Information
| Provider Information | |||||||||
| NPI: | 1063408391 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAVIN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | BERNARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17334 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212971334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034436717 | ||||||||
| FaxNumber: | 7034438643 | ||||||||
| Practice Location | |||||||||
| Address1: | 224D CORNWALL ST NW | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | LEESBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201762700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037773262 | ||||||||
| FaxNumber: | 7037773365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 02/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 0101043432 | VA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 06403620 | 05 | VA | MEDICAID | P00279876 | 01 | RR MEDICARE | OTHER |