MEDICARE: DONALD H. DEHAVEN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	ME035779	FL

General Provider Information

NPI Number	:	1003050352
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONALD H. DEHAVEN MD

Provider Business Mailing Address
First Line	:	8057 SPYGLASS HILL RD
Second Line	:	UNIT 104
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8565
Country	:	US
Telephone Number	:	321-622-8943
Fax Number	:	321-622-8945

Provider Business Practice Location Address
First Line	:	8057 SPYGLASS HILL RD
Second Line	:	UNIT 104
City	:	MELBOURNE
State	:	FL
Zip	:	32940-8565
Country	:	US
Telephone Number	:	321-622-8943
Fax Number	:	321-622-8945

Authorized Official
Title or Position	:	SOLE PROPRIETOR
Name	:	DONALD H DEHAVEN
Credential	:	MD
Telephone Number	:	321-622-8943

Provider Enumeration Date	:	04/29/2009
Last Update Date	:	04/29/2009

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