Provider Demographics
NPI:1023694890
Name:HAVERSTICK, NATHAN GRANT (DO)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:GRANT
Last Name:HAVERSTICK
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:17 DAVIS BLVD STE 308
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3438
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-9476
Practice Address - Street 1:17 DAVIS BLVD STE 308
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3438
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:813-974-9476
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
FLUO10377207RI0200X
GA13703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLUO10377OtherFLORIDA DEPARTMENT OF HEALTH
GA13703OtherGEORGIA COMPOSITE MEDICAL BOARD