Provider Demographics
NPI:1861479529
Name:GREMILLION, AVIT JOHN III (MD)
Entity type:Individual
Prefix:DR
First Name:AVIT
Middle Name:JOHN
Last Name:GREMILLION
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:FRERE
Other - Middle Name:
Other - Last Name:GREMILLION
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:962 TOMMY MUNRO DR STE E
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2139
Mailing Address - Country:US
Mailing Address - Phone:228-388-7000
Mailing Address - Fax:833-849-9899
Practice Address - Street 1:962 TOMMY MUNRO DR STE E
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2139
Practice Address - Country:US
Practice Address - Phone:228-388-7000
Practice Address - Fax:833-849-9899
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023984207W00000X, 207WX0107X
MS17239207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1486787Medicaid
MS180000355OtherMEDICARE RAILROAD
MS05109745Medicaid
MS7812033OtherAETNA
MS05109145Medicaid
MS7812033OtherAETNA
MSH08422Medicare UPIN
LA1486787Medicaid
LA5H029CX76Medicare PIN