Provider Demographics
NPI:1184722910
Name:VAN CLEVE, LAURA M (DO)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:VAN CLEVE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 S BROADWAY ST
Mailing Address - Street 2:PO BOX 7
Mailing Address - City:TOLEDO
Mailing Address - State:IA
Mailing Address - Zip Code:52342-2307
Mailing Address - Country:US
Mailing Address - Phone:641-236-0029
Mailing Address - Fax:641-484-5632
Practice Address - Street 1:1309 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:IA
Practice Address - Zip Code:52342-2307
Practice Address - Country:US
Practice Address - Phone:641-236-0029
Practice Address - Fax:641-484-5632
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA028682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0031484Medicaid
G01165Medicare UPIN
IA50962Medicare ID - Type Unspecified