Provider Demographics
NPI:1710072996
Name:VAN DUSEN, LAURA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:VAN DUSEN
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 1:1440 RENAISSANCE DR
Mailing Address - Street 2:SUIT 200
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1472
Mailing Address - Country:US
Mailing Address - Phone:847-296-3442
Mailing Address - Fax:847-296-3543
Practice Address - Street 1:1440 RENAISSANCE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1472
Practice Address - Country:US
Practice Address - Phone:847-296-3442
Practice Address - Fax:847-296-3543
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361031372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
H49197Medicare UPIN
ILK32681Medicare PIN