Provider Demographics
NPI:1003050352
Name:DONALD H. DEHAVEN MD
Entity Type:Organization
Organization Name:DONALD H. DEHAVEN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:DEHAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-622-8943
Mailing Address - Street 1:8057 SPYGLASS HILL RD
Mailing Address - Street 2:UNIT 104
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8565
Mailing Address - Country:US
Mailing Address - Phone:321-622-8943
Mailing Address - Fax:321-622-8945
Practice Address - Street 1:8057 SPYGLASS HILL RD
Practice Address - Street 2:UNIT 104
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8565
Practice Address - Country:US
Practice Address - Phone:321-622-8943
Practice Address - Fax:321-622-8945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-29
Last Update Date:2009-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME035779207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D50304Medicare UPIN
02042Medicare PIN