=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508429580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GAVIN YSETH DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2019
-----------------------------------------------------
Last Update Date | 09/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | UNIT 3215 BOX MDG
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AE
-----------------------------------------------------
Zip | 09094-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-479-2628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 MEETING HOUSE LN
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11968-5009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-726-8200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2552
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------