Provider Demographics
NPI:1235499161
Name:VAN DYNE, ELIZABETH ALLISON (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ALLISON
Last Name:VAN DYNE
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 1:4700 W SUNSET BLVD
Mailing Address - Street 2:MODULE 4-B
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6082
Mailing Address - Country:US
Mailing Address - Phone:800-954-8000
Mailing Address - Fax:
Practice Address - Street 1:4700 W SUNSET BLVD
Practice Address - Street 2:MODULE 4-B
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6082
Practice Address - Country:US
Practice Address - Phone:800-954-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119828208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics