Provider Demographics
NPI:1245793983
Name:GANTHIER, JEFFERSON VAN DIDIER (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFERSON
Middle Name:VAN DIDIER
Last Name:GANTHIER
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 1:15332 NE 5TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33162-5186
Mailing Address - Country:US
Mailing Address - Phone:786-683-8330
Mailing Address - Fax:
Practice Address - Street 1:20900 BISCAYNE BLVD
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1407
Practice Address - Country:US
Practice Address - Phone:305-682-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL153019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine