Provider Demographics
NPI:1083935100
Name:POOVENDRAN, GAYAN (MD)
Entity type:Individual
Prefix:DR
First Name:GAYAN
Middle Name:
Last Name:POOVENDRAN
Suffix:
Gender:
Credentials:MD
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 162743
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-2743
Mailing Address - Country:US
Mailing Address - Phone:954-580-4084
Mailing Address - Fax:954-530-5096
Practice Address - Street 1:10650 W STATE ROAD 84 STE 111
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33324-4235
Practice Address - Country:US
Practice Address - Phone:305-209-1951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121381207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIC334ZMedicare PIN
FLE59294Medicare UPIN