Provider Demographics
NPI:1437188091
Name:VANDERLIJN, PIETER J (MD)
Entity Type:Individual
Prefix:DR
First Name:PIETER
Middle Name:J
Last Name:VANDERLIJN
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 1:1512 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-1875
Mailing Address - Country:US
Mailing Address - Phone:715-236-2413
Mailing Address - Fax:
Practice Address - Street 1:11700 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4656
Practice Address - Country:US
Practice Address - Phone:317-688-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI444672085R0202X
IN01060551A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34201200Medicaid
IN01060551AOtherINDIANA LICENCE
BV7758949OtherDEA NUMBER