Provider Demographics
NPI:1033180187
Name:VAN DEN BROEK, JEFFERY WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:WAYNE
Last Name:VAN DEN BROEK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:10710 CHARTER DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-3128
Mailing Address - Country:US
Mailing Address - Phone:410-992-9797
Mailing Address - Fax:410-730-0942
Practice Address - Street 1:10710 CHARTER DR
Practice Address - Street 2:SUITE 110
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-3128
Practice Address - Country:US
Practice Address - Phone:410-992-9797
Practice Address - Fax:410-730-0942
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
HIDOS-945207RG0100X
MDH0075616207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology