Provider Demographics
NPI:1083838312
Name:VAN BALVEREN, MARK DAVID (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:VAN BALVEREN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 N. MILITARY TRAIL
Mailing Address - Street 2:PHYSICAL MEDICINE (117)
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33410
Mailing Address - Country:US
Mailing Address - Phone:561-422-5732
Mailing Address - Fax:561-422-8289
Practice Address - Street 1:7305 N. MILITARY TRAIL
Practice Address - Street 2:PHYSICAL MEDICINE (117)
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33410
Practice Address - Country:US
Practice Address - Phone:561-422-5732
Practice Address - Fax:561-422-8289
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22429174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist