Provider Demographics
NPI:1689684466
Name:VAN, DAWN T (OD)
Entity Type:Individual
Prefix:DR
First Name:DAWN
Middle Name:T
Last Name:VAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8794 BOYNTON BEACH BLVD STE 114
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33472-4468
Mailing Address - Country:US
Mailing Address - Phone:561-509-8502
Mailing Address - Fax:561-509-8469
Practice Address - Street 1:8794 BOYNTON BEACH BLVD STE 114
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33472-4468
Practice Address - Country:US
Practice Address - Phone:561-509-8502
Practice Address - Fax:561-509-8469
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3746152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621054600Medicaid
FL621054600Medicaid
U96128Medicare UPIN