Provider Demographics
NPI:1477642098
Name:VAN DE VYVER, PAUL L (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:VAN DE VYVER
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-4054
Practice Address - Fax:682-885-7497
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6674207L00000X, 207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1186800OtherUHC PIN
TX124065OtherSUPERIOR PIN
TX00N47FOtherMEDICARE GROUP PIN
TX048568201Medicaid
TX138104806Medicaid
TX88073GOtherBCBSTX IND PIN
TX138104812OtherCSHCN
1447220850OtherGRP NPI NUMBER
TX470199OtherPHCS PIN
TX5587438OtherAETNA PIN
TX00N47FOtherBCBSTX GRP PIN
TX126004100OtherFIRSTCARE PIN
TX137345809OtherMEDICAID GROUP TPI
TX140442853OtherCSHCN GROUP TPI
TX1640381OtherFIRSTHEALTH PIN
TX9829768OtherCIGNA PIN
TX10009778OtherAMERIGROUP PIN
TX124065OtherSUPERIOR PIN
TX138104812OtherCSHCN