Provider Demographics
NPI:1861424624
Name:GAVIN, KEVIN SEAN (DPM)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:SEAN
Last Name:GAVIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-2741
Mailing Address - Country:US
Mailing Address - Phone:847-458-1800
Mailing Address - Fax:847-458-8447
Practice Address - Street 1:1219 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-2741
Practice Address - Country:US
Practice Address - Phone:847-458-1800
Practice Address - Fax:847-458-8447
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004743213ES0103X, 213E00000X, 213EP0504X, 213EP1101X, 213ER0200X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP0504XPodiatric Medicine & Surgery Service ProvidersPodiatristPublic Medicine
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01606879OtherBLUE CROSS BLUE SHIELD
IL480023961OtherRAILROAD MEDICARE
IL5090108OtherAETNA
IL5090108OtherAETNA