Provider Demographics
NPI:1598714578
Name:POPOVETSKY, GARY (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:POPOVETSKY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 COOPER WAY
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-3479
Mailing Address - Country:US
Mailing Address - Phone:561-822-3296
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:305-682-7292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07360200207P00000X
FLOS11198207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003164600Medicaid
H68658Medicare UPIN