Provider Demographics
NPI:1043203003
Name:HAVAS, JEREMY DAVID (DO)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:HAVAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2463
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34423-2463
Mailing Address - Country:US
Mailing Address - Phone:352-795-5862
Mailing Address - Fax:352-795-9262
Practice Address - Street 1:1902 WESTOVER RESERVE BLVD
Practice Address - Street 2:
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-6221
Practice Address - Country:US
Practice Address - Phone:352-795-5862
Practice Address - Fax:352-795-9262
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL00073522085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254717100Medicaid
FLG47193Medicare UPIN
FL44478Medicare PIN