Provider Demographics
NPI:1053330571
Name:HAVENSTEIN, PAUL D (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:D
Last Name:HAVENSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15294 101ST TRL N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-6846
Mailing Address - Country:US
Mailing Address - Phone:313-363-1269
Mailing Address - Fax:
Practice Address - Street 1:15294 101ST TRL N
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33478-6846
Practice Address - Country:US
Practice Address - Phone:313-363-1269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058243207L00000X
FL135335207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4088643-10Medicaid