Provider Demographics
NPI:1366286577
Name:GAVIOLA, EDWARD D
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:D
Last Name:GAVIOLA
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 1:10089 WILLOW CREEK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-1699
Mailing Address - Country:US
Mailing Address - Phone:858-722-9036
Mailing Address - Fax:
Practice Address - Street 1:10089 WILLOW CREEK RD STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-1699
Practice Address - Country:US
Practice Address - Phone:858-722-9036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246RP1900X
CACPA0002388246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy