Provider Demographics
NPI:1063408391
Name:GAVIN, MATTHEW BERNARD (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BERNARD
Last Name:GAVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 D CORNWALL STREET NW
Mailing Address - Street 2:STE 403
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:224-D CORNWALL STREET, NW, SUITE 204,
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-2700
Practice Address - Country:US
Practice Address - Phone:703-777-3262
Practice Address - Fax:703-777-3365
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043432207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30015898270001Medicaid
VA06403620Medicaid
VA1063408391Medicaid
P00279876OtherRR MEDICARE