Provider Demographics
NPI:1609356591
Name:HAVEN, BRIAN THOMAS (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:THOMAS
Last Name:HAVEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5172
Mailing Address - Country:US
Mailing Address - Phone:909-863-1097
Mailing Address - Fax:
Practice Address - Street 1:11980 MOUNT VERNON AVE
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5172
Practice Address - Country:US
Practice Address - Phone:909-863-1097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPOD-001008213ES0103X
CAE6017213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery