Provider Demographics
NPI:1053508721
Name:GARY M VAN DEVENTER MD
Entity Type:Organization
Organization Name:GARY M VAN DEVENTER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAN DEVENTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-963-3336
Mailing Address - Street 1:PO BOX 50706
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93150-0706
Mailing Address - Country:US
Mailing Address - Phone:805-963-3336
Mailing Address - Fax:805-564-3332
Practice Address - Street 1:221 W PUEBLO ST
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-6814
Practice Address - Country:US
Practice Address - Phone:805-563-0024
Practice Address - Fax:805-563-1454
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100004009OtherRAILROAD MEDICARE
CA100004009OtherRAILROAD MEDICARE