Provider Demographics
NPI:1225285992
Name:VAN TIL, BRENT (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:VAN TIL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 WASHINGTON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7724
Mailing Address - Country:US
Mailing Address - Phone:616-392-7472
Mailing Address - Fax:616-392-3327
Practice Address - Street 1:904 WASHINGTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7724
Practice Address - Country:US
Practice Address - Phone:616-392-7472
Practice Address - Fax:616-392-3327
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002387213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5901002387OtherLICENSE
MI0M15760Medicare PIN