Provider Demographics
NPI:1942357751
Name:MOMON, VAN C (MD)
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:C
Last Name:MOMON
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:HENRY FORD HEALTH SYSTEM
Mailing Address - Street 2:5500 AUTO CLUB DRIVE, SUITE 160
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126
Mailing Address - Country:US
Mailing Address - Phone:313-425-4700
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD HEALTH SYSTEM
Practice Address - Street 2:5500 AUTO CLUB DRIVE, SUITE 160
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-425-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301047888208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI175499010Medicaid
700H262280OtherBLUE CROSS-BLUE CROSS
VM047888OtherCHAMPUS-CHAMPUS
VM047888OtherCOMMERCIAL-COMMERCIAL NUMBER
VM047888OtherCOMMERCIAL-COMMERCIAL NUMBER
MI175499010Medicaid