Provider Demographics
NPI:1609867696
Name:HAVKIN, BORIS (MD)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:HAVKIN
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 1:3021 W EAU GALLIE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7005
Mailing Address - Country:US
Mailing Address - Phone:321-500-4545
Mailing Address - Fax:321-425-4000
Practice Address - Street 1:3021 W EAU GALLIE BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7005
Practice Address - Country:US
Practice Address - Phone:321-500-4545
Practice Address - Fax:321-425-4000
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90111208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL37966OtherBCBS
FLP01164118OtherRR MEDICARE
FL269433600Medicaid
FL269433600Medicaid
FL37966YMedicare PIN