Provider Demographics
NPI:1699866335
Name:WIDOM, GAVIN JAY (DC)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:JAY
Last Name:WIDOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:MS
Other - First Name:SONIA
Other - Middle Name:KIOKO
Other - Last Name:HORVATH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1400 GOODLETTE RD N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5258
Mailing Address - Country:US
Mailing Address - Phone:239-263-3332
Mailing Address - Fax:239-262-4780
Practice Address - Street 1:1400 GOODLETTE RD N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5258
Practice Address - Country:US
Practice Address - Phone:239-263-3332
Practice Address - Fax:239-262-4780
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006230111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT45232Medicare UPIN
FL22573Medicare ID - Type UnspecifiedCHIROPRACTIC