Provider Demographics
NPI:1568212611
Name:VAN PEVENAGE, PEYTON M (MD)
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:M
Last Name:VAN PEVENAGE
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 670212
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45267
Mailing Address - Country:US
Mailing Address - Phone:513-558-4592
Mailing Address - Fax:513-558-2220
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219
Practice Address - Country:US
Practice Address - Phone:513-558-4592
Practice Address - Fax:513-558-2220
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program