Provider Demographics
NPI:1487664942
Name:GOVER HAVENER, MYRNA IVELISSE (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRNA
Middle Name:IVELISSE
Last Name:GOVER HAVENER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MYRNA
Other - Middle Name:IVELISSE
Other - Last Name:GOVER LEPICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:1780 OLD HIGHWAY 50 E
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MO
Practice Address - Zip Code:63084
Practice Address - Country:US
Practice Address - Phone:888-403-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010036458207R00000X, 207R00000X
TXL0439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2010036458OtherMISSOURI STATE BOARD OF REGISTRATION
TX145265801Medicaid
TX8653M4Medicare Oscar/Certification