Provider Demographics
NPI:1508847229
Name:DEHAVEN, DONALD HARRY (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:HARRY
Last Name:DEHAVEN
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 1:8041 SPYGLASS HILL RD
Mailing Address - Street 2:UNIT 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8559
Mailing Address - Country:US
Mailing Address - Phone:321-622-8943
Mailing Address - Fax:321-622-8945
Practice Address - Street 1:8041 SPYGLASS HILL RD
Practice Address - Street 2:UNIT 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-8559
Practice Address - Country:US
Practice Address - Phone:321-622-8943
Practice Address - Fax:321-622-8945
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME035779207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1068059OtherCAREPLUS MEDICARE
FL01257726OtherAMERIGROUP
FLP00018595OtherRAILROAD MEDICARE
FL02042OtherBLUE CROSS BLUE SHIELD
19335OtherFIRST HEALTHY
FL225693OtherWELLCARE
FL5255803008OtherCIGNA
FL1068059OtherCAREPLUS MEDICARE
19335OtherFIRST HEALTHY
D50304Medicare UPIN