Provider Demographics
NPI:1366928574
Name:GORRELL, GAVIN ARTHUR (MD)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:ARTHUR
Last Name:GORRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8801 HORIZON BLVD NE STE 360
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1563
Mailing Address - Country:US
Mailing Address - Phone:505-828-4923
Mailing Address - Fax:505-213-0103
Practice Address - Street 1:2947 RODEO PARK DR E
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6303
Practice Address - Country:US
Practice Address - Phone:505-983-6613
Practice Address - Fax:505-986-9984
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-0431207W00000X, 207W00000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35670029Medicaid
NM2G1824OtherMEDICARE PTAN