Provider Demographics
NPI:1043218084
Name:EARNHART, JOHN VAN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:VAN
Last Name:EARNHART
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 1:150 S MOUNT AUBURN RD
Mailing Address - Street 2:SUITE 418
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4911
Mailing Address - Country:US
Mailing Address - Phone:573-332-6000
Mailing Address - Fax:
Practice Address - Street 1:150 S MOUNT AUBURN RD
Practice Address - Street 2:SUITE 418
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4911
Practice Address - Country:US
Practice Address - Phone:573-332-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2014-01-31
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-05-01
Provider Licenses
StateLicense IDTaxonomies
IL036-106126207Q00000X
MO2013002771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH67921OtherBLUE CROSS BLUE SHIELD
IL076839OtherHEALTH ALLIANCE
ILH67921OtherCHAMPVA
ILH67921OtherTRICARE
IL036-106126Medicaid
IL036106126OtherIDPA FEE FOR SERVICE
ILH67921OtherUNITED HEALTHCARE RR MEDI
MO1043218084Medicaid
IL473444OtherHEALTHLINK
ILH67921OtherBLUE CROSS BLUE SHIELD
ILH67921OtherUNITED HEALTHCARE RR MEDI
ILL92883Medicare ID - Type Unspecified