Provider Demographics
NPI:1023035540
Name:VINES, RICHARD VAN II (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:VAN
Last Name:VINES
Suffix:II
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 1:920 OLIVER ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201
Mailing Address - Country:US
Mailing Address - Phone:318-329-9202
Mailing Address - Fax:318-329-1258
Practice Address - Street 1:920 OLIVER ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201
Practice Address - Country:US
Practice Address - Phone:318-329-9202
Practice Address - Fax:318-329-9202
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA017884207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366781Medicaid
LA52992Medicare ID - Type Unspecified
LA1366781Medicaid