Provider Demographics
NPI:1073507745
Name:VAN DEN DRIESSCHE, THOMAS P (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:VAN DEN DRIESSCHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3030 LAKE AVE
Mailing Address - Street 2:SUITE 32
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5428
Mailing Address - Country:US
Mailing Address - Phone:260-424-3134
Mailing Address - Fax:260-424-3138
Practice Address - Street 1:3030 LAKE AVE
Practice Address - Street 2:SUITE32
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5428
Practice Address - Country:US
Practice Address - Phone:260-424-3134
Practice Address - Fax:260-424-3138
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01028709A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND95420Medicare UPIN
IN142990Medicare PIN