Provider Demographics
NPI:1841380433
Name:VAN STADEN, GAVIN NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:NICHOLAS
Last Name:VAN STADEN
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 1:3400 QUADRANGLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-1492
Mailing Address - Country:US
Mailing Address - Phone:407-266-3627
Mailing Address - Fax:407-822-4799
Practice Address - Street 1:3400 QUADRANGLE BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-1492
Practice Address - Country:US
Practice Address - Phone:407-266-3627
Practice Address - Fax:407-822-4799
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME163077207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00458325Medicare PIN
I41802Medicare UPIN
UT000062159Medicare PIN