Healthcare Provider Details

I. General information

NPI: 1508429580
Provider Name (Legal Business Name): GAVIN YSETH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 3215 BOX MDG
APO AE
09094-3215
US

IV. Provider business mailing address

240 MEETING HOUSE LN
SOUTHAMPTON NY
11968-5009
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-2628
  • Fax:
Mailing address:
  • Phone: 631-726-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2552
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: