Provider Demographics
NPI:1851378558
Name:VAN PUTTEN, DOUGLAS J (MD,FACS)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:VAN PUTTEN
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11370 ANDERSON ST # 1800
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2154
Mailing Address - Fax:
Practice Address - Street 1:11370 ANDERSON ST # 1800
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2154
Practice Address - Fax:909-558-2180
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039408A207W00000X, 208200000X
CAG58345207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01039408AOtherPHYSICIAN LICENSE
IN100335580Medicaid
IN000000342157OtherANTHEM BC/BS
INE84237Medicare UPIN
IN100335580Medicaid
IN218780AMedicare PIN
IN6241950001Medicare NSC
INP00180844Medicare PIN