Provider Demographics
NPI:1962434373
Name:UDSTUEN, GAVIN J (MD)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:J
Last Name:UDSTUEN
Suffix:
Gender:M
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 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3107
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:DEPT. OF RADIOLOGY
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-1000
Practice Address - Country:US
Practice Address - Phone:513-584-7544
Practice Address - Fax:513-584-9100
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-11702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000228669OtherANTHEM
OH300134540OtherRAILROAD MEDICARE
WV1805944000Medicaid
OH1603249OtherUNITED HEALTHCARE
OH2214857Medicaid
IN200411300AMedicaid
OH2903618OtherAETNA
KY64028558Medicaid
OHH21669Medicare UPIN
OH2214857Medicaid