Healthcare Provider Details

I. General information

NPI: 1114125176
Provider Name (Legal Business Name): HAVYN SKORUPAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WYOMING ST
DAYTON OH
45409-2722
US

IV. Provider business mailing address

124 WISTERIA DR
OAKWOOD OH
45419-3453
US

V. Phone/Fax

Practice location:
  • Phone: 724-272-9837
  • Fax:
Mailing address:
  • Phone: 724-272-9837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberOS014318
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: