Provider Demographics
NPI:1659300531
Name:HAVESON, STEPHEN P (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
Last Name:HAVESON
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:PO BOX 95000-2424
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2424
Mailing Address - Country:US
Mailing Address - Phone:212-529-2407
Mailing Address - Fax:212-529-2469
Practice Address - Street 1:306 E 15TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-529-2407
Practice Address - Fax:212-529-2469
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1005412086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00172394Medicaid
NY00172394Medicaid
B16930Medicare UPIN