Provider Demographics
NPI:1710991997
Name:VAN, MARCUS MINH (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:MINH
Last Name:VAN
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 1:2717 E EVANS RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-6066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8216 STARLAND DR
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-1877
Practice Address - Country:US
Practice Address - Phone:310-621-1750
Practice Address - Fax:855-473-0120
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA832082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A832080Medicaid
CAWA83208CMedicare PIN
CAWA83208IMedicare PIN
CAWA83208DMedicare PIN
I71047Medicare UPIN
CA00A832080Medicaid
CAWA83208HMedicare PIN
CAWA83208EMedicare PIN
CAP00462023Medicare PIN