Provider Demographics
NPI:1518064112
Name:VANOOYEN, MARINUS (MD)
Entity Type:Individual
Prefix:DR
First Name:MARINUS
Middle Name:
Last Name:VANOOYEN
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 1:2625 LIGHTHOUSE BEND DR
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32082-3702
Mailing Address - Country:US
Mailing Address - Phone:904-285-2905
Mailing Address - Fax:904-285-2905
Practice Address - Street 1:3416 BIRNWICK DR
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221
Practice Address - Country:US
Practice Address - Phone:517-263-8975
Practice Address - Fax:517-264-5997
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010303002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4992126Medicaid
MI4992126Medicaid
MI1840002Medicare PIN
MIMI1840002Medicare PIN
MIP41100002Medicare ID - Type Unspecified
B46411Medicare UPIN
OHVA4264571Medicare PIN