Provider Demographics
NPI:1285628933
Name:VAN DEVENTER, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:VAN DEVENTER
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: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:805-563-0024
Mailing Address - Fax:805-563-1454
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
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC39157207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100004009OtherRAILROAD MEDICARE
CA00C391570Medicaid
CA100004009OtherRAILROAD MEDICARE
A88084Medicare UPIN