Provider Demographics
NPI:1407817190
Name:SNIDER, VAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:A
Last Name:SNIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 RYAN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5252
Mailing Address - Country:US
Mailing Address - Phone:337-497-9355
Mailing Address - Fax:337-437-3692
Practice Address - Street 1:1106 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601
Practice Address - Country:US
Practice Address - Phone:337-497-9355
Practice Address - Fax:337-437-3692
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD019378207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1900010Medicaid
LA5M777Medicare ID - Type Unspecified
LA1900010Medicaid