Provider Demographics
NPI:1083050900
Name:VAN, HAILEE (MD)
Entity Type:Individual
Prefix:
First Name:HAILEE
Middle Name:
Last Name:VAN
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 1:7060 CLAIREMONT MESA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-1003
Mailing Address - Country:US
Mailing Address - Phone:714-386-2653
Mailing Address - Fax:
Practice Address - Street 1:7060 CLAIREMONT MESA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1003
Practice Address - Country:US
Practice Address - Phone:714-386-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-19
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207Q00000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program