Provider Demographics
NPI:1902870744
Name:GAVIN, MARTIN A (PT, DPM)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:A
Last Name:GAVIN
Suffix:
Gender:M
Credentials:PT, DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 MILL HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-0120
Mailing Address - Country:US
Mailing Address - Phone:203-336-7312
Mailing Address - Fax:
Practice Address - Street 1:17 BROOKDALE AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-5934
Practice Address - Country:US
Practice Address - Phone:203-336-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPT002233225100000X
CTP00368213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery