Provider Demographics
NPI:1114983020
Name:GERVIN, STEPHEN ZISL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ZISL
Last Name:GERVIN
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 1:2301 N UNIVERSITY DRIVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024
Mailing Address - Country:US
Mailing Address - Phone:954-961-3365
Mailing Address - Fax:954-961-5629
Practice Address - Street 1:2301 N UNIVERSITY DR
Practice Address - Street 2:SUITE 210
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3617
Practice Address - Country:US
Practice Address - Phone:954-961-3365
Practice Address - Fax:954-961-5629
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME13977174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06731ZMedicare PIN