Provider Demographics
NPI:1497763999
Name:HAVENS, GARY JORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JORDAN
Last Name:HAVENS
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 1:607 N CENTRAL AVE
Mailing Address - Street 2:SUITE #208
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1804
Mailing Address - Country:US
Mailing Address - Phone:818-551-6666
Mailing Address - Fax:818-551-6660
Practice Address - Street 1:607 N CENTRAL AVE
Practice Address - Street 2:SUITE #208
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1804
Practice Address - Country:US
Practice Address - Phone:818-551-6666
Practice Address - Fax:818-551-6660
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG12325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA38622Medicare UPIN