Provider Demographics
NPI:1205885068
Name:VAN ARSDELL, KENT HOWARD (MD)
Entity type:Individual
Prefix:
First Name:KENT
Middle Name:HOWARD
Last Name:VAN ARSDELL
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:PO BOX 12938
Mailing Address - Street 2:C/O CLINIC MANAGEMENT
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 TIMMS RD NE
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701-7016
Practice Address - Country:US
Practice Address - Phone:706-625-0022
Practice Address - Fax:706-625-8586
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65430207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003101492CMedicaid
GA003101492AMedicaid
GA202I113142Medicare PIN
TN3080442Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
TN3057214Medicaid