Provider Demographics
NPI:1629060256
Name:VAN HEUVELEN, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:VAN HEUVELEN
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 3868
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3868
Mailing Address - Country:US
Mailing Address - Phone:509-228-1000
Mailing Address - Fax:509-252-9300
Practice Address - Street 1:1440 E MULLAN AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-9064
Practice Address - Country:US
Practice Address - Phone:509-228-1000
Practice Address - Fax:509-252-9300
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY12377C2085R0001X
IDM53102085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003989600Medicaid
920003975OtherRAILROAD MEDICARE
WA20006102Medicare PIN
920003975OtherRAILROAD MEDICARE
ID003989600Medicaid