Provider Demographics
NPI:1275699266
Name:VAN DIS, JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:
Last Name:VAN DIS
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 1:601 ELMWOOD AVE DEPT OBGYN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:310-254-7023
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE DEPT OBGYN
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-1437
Practice Address - Country:US
Practice Address - Phone:585-276-5368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308289363AM0700X, 207V00000X
MN50732207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY308289OtherSTATTE LICENSE
MN50732OtherSTATE LICENSE
CAA90758OtherSTATE LICENSE