Provider Demographics
NPI:1730256165
Name:GAVIN, DONNA L (OD)
Entity type:Individual
Prefix:DR
First Name:DONNA
Middle Name:L
Last Name:GAVIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 INTREPID LN
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02835-1830
Mailing Address - Country:US
Mailing Address - Phone:401-423-3507
Mailing Address - Fax:401-423-3501
Practice Address - Street 1:17 INTREPID LN
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02835-1830
Practice Address - Country:US
Practice Address - Phone:401-423-3507
Practice Address - Fax:401-423-3501
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA00363152WL0500X
MA2773152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI419009780Medicare ID - Type Unspecified
RIT53277Medicare UPIN