MEDICARE: DR. GAYAN POOVENDRAN 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	207QS0010X	Sports Medicine (Family Medicine) Physician	ME121381	FL

General Provider Information

NPI Number	:	1083935100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GAYAN POOVENDRAN MD

Provider Business Mailing Address
First Line	:	PO BOX 162743
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32716-2743
Country	:	US
Telephone Number	:	954-580-4084
Fax Number	:	954-530-5096

Provider Business Practice Location Address
First Line	:	10650 W STATE ROAD 84 STE 111
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33324-4235
Country	:	US
Telephone Number	:	305-209-1951
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	04/07/2025

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