Provider Demographics
NPI:1659353738
Name:HAVENS, PAUL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
Last Name:HAVENS
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 1:912 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LITTLEFORK
Mailing Address - State:MN
Mailing Address - Zip Code:56653-9357
Mailing Address - Country:US
Mailing Address - Phone:218-278-6634
Mailing Address - Fax:218-278-6637
Practice Address - Street 1:912 MAIN STREET
Practice Address - Street 2:
Practice Address - City:LITTLEFORK
Practice Address - State:MN
Practice Address - Zip Code:56653-9357
Practice Address - Country:US
Practice Address - Phone:218-278-6634
Practice Address - Fax:218-278-6637
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8194207Q00000X
MN24789207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV0020-14029Medicaid
NV2014029Medicaid
D48624Medicare UPIN
NV0020-14029Medicaid