Provider Demographics
NPI:1306529490
Name:BOLDIZSAR, GAVIN D
Entity type:Individual
Prefix:MR
First Name:GAVIN
Middle Name:D
Last Name:BOLDIZSAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 NW ORCHARD HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1397
Mailing Address - Country:US
Mailing Address - Phone:541-760-8845
Mailing Address - Fax:
Practice Address - Street 1:2411 MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5824
Practice Address - Country:US
Practice Address - Phone:541-682-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW00019404175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist