Provider Demographics
NPI:1942512629
Name:VAN, CHRISTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TUNG
Other - Middle Name:
Other - Last Name:VAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:108 PEACE AVE
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-4583
Mailing Address - Country:US
Mailing Address - Phone:773-213-6613
Mailing Address - Fax:
Practice Address - Street 1:108 PEACE AVE
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-4583
Practice Address - Country:US
Practice Address - Phone:773-213-6613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.00260363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical