Provider Demographics
NPI:1588779607
Name:GAVIGAN, MICHAEL K (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:K
Last Name:GAVIGAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:K
Other - Last Name:GAVIGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:PO BOX 3227
Mailing Address - Street 2:SUITE #17
Mailing Address - City:POCASSET
Mailing Address - State:MA
Mailing Address - Zip Code:02559-3227
Mailing Address - Country:US
Mailing Address - Phone:508-563-7133
Mailing Address - Fax:
Practice Address - Street 1:4 BARLOWS LANDING RD
Practice Address - Street 2:SUITE #17
Practice Address - City:POCASSET
Practice Address - State:MA
Practice Address - Zip Code:02559-1980
Practice Address - Country:US
Practice Address - Phone:508-563-7133
Practice Address - Fax:508-563-6771
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1770213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588779607OtherBCBS
NJ27-07976OtherEVERCARE
MA33081OtherHPHC
MA710223OtherTUFTS
MA0361704OtherMEDICAID
1588779607OtherBCBS
P00455686Medicare PIN
Y70831Medicare UPIN