Provider Demographics
NPI:1982722534
Name:HAVENS, RALPH D (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:D
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 1:380 WINSLOW WAY E
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2424
Mailing Address - Country:US
Mailing Address - Phone:206-842-5632
Mailing Address - Fax:
Practice Address - Street 1:380 WINSLOW WAY E
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2424
Practice Address - Country:US
Practice Address - Phone:206-842-5632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20008322390200000X
WAMD60072857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8958987Medicare PIN
WAG8958988Medicare PIN