Provider Demographics
NPI:1811945355
Name:GAUBY, VAN ALAN (MD)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:ALAN
Last Name:GAUBY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:93 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HILTON HEAD
Practice Address - State:SC
Practice Address - Zip Code:29926-6613
Practice Address - Country:US
Practice Address - Phone:843-681-3777
Practice Address - Fax:843-681-9996
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD22856207Q00000X
SCT6915207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT69156Medicaid
SCE77884Medicare UPIN
SCE778847919Medicare PIN
SCT69156Medicaid
SCP00247872Medicare PIN