Provider Demographics
NPI:1215933940
Name:POWELL, GAVIN ROSS (MD)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:ROSS
Last Name:POWELL
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 1:318 2ND ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3765
Mailing Address - Country:US
Mailing Address - Phone:208-467-3006
Mailing Address - Fax:208-467-1155
Practice Address - Street 1:318 2ND ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3765
Practice Address - Country:US
Practice Address - Phone:208-467-3006
Practice Address - Fax:208-467-1155
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7519207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805173400Medicaid
ID1376908Medicare ID - Type Unspecified
IDG40165Medicare UPIN