Basic Information
| Provider Information | |||||||||
| NPI: | 1992773303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAVOY | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | GERALD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1890 LPGA BLVD | ||||||||
| Address2: | STE. 160 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321177130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862524701 | ||||||||
| FaxNumber: | 3862539410 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 LPGA BLVD | ||||||||
| Address2: | STE. 160 | ||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321177130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862524701 | ||||||||
| FaxNumber: | 3862539410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 05/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME54029 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 4055441 | 01 | AETNA | OTHER | 00551 | 01 | BC BS | OTHER | 049302300 | 05 | FL | MEDICAID |