Basic Information
| Provider Information | |||||||||
| NPI: | 1811945355 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAUBY | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 93 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HILTON HEAD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299266613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436813777 | ||||||||
| FaxNumber: | 8436819996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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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 | 207P00000X | T6915 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | MD22856 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | T69156 | 05 | SC | MEDICAID |