Provider Demographics
NPI:1104911262
Name:GAVENCAK, JOHN CROCIRTO (DC)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CROCIRTO
Last Name:GAVENCAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTER MARICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11934
Mailing Address - Country:US
Mailing Address - Phone:631-399-8888
Mailing Address - Fax:631-399-3246
Practice Address - Street 1:326 MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTER MORICHES
Practice Address - State:NY
Practice Address - Zip Code:11934-3509
Practice Address - Country:US
Practice Address - Phone:631-399-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX010539111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX6G411Medicare ID - Type Unspecified
NYU96215Medicare UPIN