Provider Demographics
NPI:1114994266
Name:VAN LEUVEN, MARK (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:VAN LEUVEN
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 1:564 HOOSICK ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2106
Mailing Address - Country:US
Mailing Address - Phone:518-273-2715
Mailing Address - Fax:518-273-2815
Practice Address - Street 1:564 HOOSICK ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2106
Practice Address - Country:US
Practice Address - Phone:518-273-2715
Practice Address - Fax:518-273-2815
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015588-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02251054Medicaid
NYP27259Medicare UPIN
NYCC4736Medicare ID - Type Unspecified
NY02251054Medicaid