Provider Demographics
NPI:1992783203
Name:GRAVINO, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GRAVINO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6265 ROCK CHALK DR
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049
Mailing Address - Country:US
Mailing Address - Phone:785-842-5070
Mailing Address - Fax:785-505-5264
Practice Address - Street 1:6265 ROCK CHALK DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049
Practice Address - Country:US
Practice Address - Phone:785-842-5070
Practice Address - Fax:785-505-5264
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0518210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSC60015Medicare UPIN
KS057595Medicare ID - Type Unspecified