Provider Demographics
NPI:1134330400
Name:VAN, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:VAN
Suffix:
Gender:M
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:PO BOX 3370
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70434-3370
Mailing Address - Country:US
Mailing Address - Phone:985-867-8585
Mailing Address - Fax:985-867-3644
Practice Address - Street 1:1970 N HIGHWAY 190
Practice Address - Street 2:SUITE 100
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-5158
Practice Address - Country:US
Practice Address - Phone:985-867-8585
Practice Address - Fax:985-867-3644
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD.203954207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02774204Medicaid
LA50962Medicaid
LA50962Medicaid