Provider Demographics
NPI:1154326544
Name:VAN ANDEL, RODNEY KENT (MD)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:KENT
Last Name:VAN ANDEL
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 5500
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75712-5500
Mailing Address - Country:US
Mailing Address - Phone:903-324-6450
Mailing Address - Fax:903-593-7569
Practice Address - Street 1:3203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LINDALE
Practice Address - State:TX
Practice Address - Zip Code:75771-7727
Practice Address - Country:US
Practice Address - Phone:903-266-4000
Practice Address - Fax:903-882-7751
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7909207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138771100OtherFIRSTCARE SOUTHWEST
TXP00165779OtherRAILROAD MEDICARE
TX166412003Medicaid
TX8K1901OtherTEXAS BCBS
TXTIN PLUS 001OtherTRICARE CANTON LOCATION
TXTIN PLUS 002OtherTRICARE LAKE PALESTINE LOCATION
TXTIN PLUS 028OtherTRICARE
TXPP10013213OtherTEXAS WORKERS COMP
TX129375OtherCHIPS
TX8V5495OtherBCBS
TX166412001Medicaid
TXP00886861Medicare PIN
TXTIN PLUS 001OtherTRICARE CANTON LOCATION
TX138771100OtherFIRSTCARE SOUTHWEST
TXPP10013213OtherTEXAS WORKERS COMP