Provider Demographics
NPI:1164714556
Name:VAN ELK, KIMBERLY SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SUE
Last Name:VAN ELK
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 1:7520 TOSCANA CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8056
Mailing Address - Country:US
Mailing Address - Phone:765-748-2309
Mailing Address - Fax:574-233-3125
Practice Address - Street 1:200 HIGH PARK AVE
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4810
Practice Address - Country:US
Practice Address - Phone:574-364-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073789207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201110000Medicaid