Provider Demographics
NPI:1821173410
Name:VAN GURP, JOHN RONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RONALD
Last Name:VAN GURP
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 1:3111 SPRINGBANK LN
Mailing Address - Street 2:SUITE J
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-3372
Mailing Address - Country:US
Mailing Address - Phone:704-541-6001
Mailing Address - Fax:704-541-1563
Practice Address - Street 1:3111 SPRINGBANK LN
Practice Address - Street 2:SUITE J
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3372
Practice Address - Country:US
Practice Address - Phone:704-541-6001
Practice Address - Fax:704-541-1563
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34488207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2159988Medicare ID - Type Unspecified
NCE68630Medicare UPIN