Healthcare Provider Details

I. General information

NPI: 1083935100
Provider Name (Legal Business Name): GAYAN POOVENDRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10650 W STATE ROAD 84 STE 111
DAVIE FL
33324-4235
US

IV. Provider business mailing address

PO BOX 162743
ALTAMONTE SPRINGS FL
32716-2743
US

V. Phone/Fax

Practice location:
  • Phone: 305-209-1951
  • Fax:
Mailing address:
  • Phone: 954-580-4084
  • Fax: 954-530-5096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME121381
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: