Provider Demographics
NPI:1376604728
Name:VAN BENTHUYSEN, DEREK ANDREW (DC)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:ANDREW
Last Name:VAN BENTHUYSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 HIGHWAY 138
Mailing Address - Street 2:STE 227
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9694
Mailing Address - Country:US
Mailing Address - Phone:732-280-1800
Mailing Address - Fax:732-280-2323
Practice Address - Street 1:3350 HIGHWAY 138
Practice Address - Street 2:STE 227
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9694
Practice Address - Country:US
Practice Address - Phone:732-280-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC05589111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ035895Medicare ID - Type Unspecified
NJU79653Medicare UPIN