Provider Demographics
NPI:1073686762
Name:VAN DE POLDER, JEAN (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:VAN DE POLDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11059 E BETHANY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80014-2622
Mailing Address - Country:US
Mailing Address - Phone:303-617-2300
Mailing Address - Fax:303-617-2397
Practice Address - Street 1:1646 ELMIRA ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80010-2122
Practice Address - Country:US
Practice Address - Phone:303-617-2498
Practice Address - Fax:303-617-2832
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO182682084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
COAV5642524OtherDEA