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: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 DOOLITTLE DR BLDG 6000
ELLSWORTH AFB SD
57706-4821
US

IV. Provider business mailing address

2900 DOOLITTLE DR BLDG 6000
ELLSWORTH AFB SD
57706-4821
US

V. Phone/Fax

Practice location:
  • Phone: 605-385-6700
  • Fax:
Mailing address:
  • Phone: 605-385-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2552
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: