Provider Demographics
NPI:1659453405
Name:VAN VALKENBURGH, ILVA E (MD)
Entity Type:Individual
Prefix:
First Name:ILVA
Middle Name:E
Last Name:VAN VALKENBURGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W SILVER SPRING DR
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-885-0080
Mailing Address - Fax:414-885-0081
Practice Address - Street 1:305 W SILVER SPRING DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217
Practice Address - Country:US
Practice Address - Phone:414-885-0080
Practice Address - Fax:414-885-0081
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI382210202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400278502OtherMEDICARE PTAN
WI32302400Medicaid
WIK400278502OtherMEDICARE PTAN