Provider Demographics
NPI:1730130014
Name:VAN OOSTROM, TREVOR (MD)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:VAN OOSTROM
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 853
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-0853
Mailing Address - Country:US
Mailing Address - Phone:907-745-0374
Mailing Address - Fax:907-745-0200
Practice Address - Street 1:2500 S WOODWORTH LOOP
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8984
Practice Address - Country:US
Practice Address - Phone:907-745-0374
Practice Address - Fax:907-745-0200
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5592174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0271Medicaid
AKP00283147OtherVANOO RAILROAD MCR#
AKCI9459OtherGROUPS RR MCR#
AKMDG417Medicaid
AKMDG417Medicaid
AKCI9459OtherGROUPS RR MCR#