Provider Demographics
NPI:1093395303
Name:GRAVENSTEIN, MICHAEL STEFAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEFAN
Last Name:GRAVENSTEIN
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 1:4101 NW 89TH BLVD RM 1788
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-3813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4101 NW 89TH BLVD RM 1788
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-3813
Practice Address - Country:US
Practice Address - Phone:352-265-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-11
Last Update Date:2021-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program