Provider Demographics
NPI:1265588479
Name:VAN DAM, LORENE ANN (DPM)
Entity type:Individual
Prefix:DR
First Name:LORENE
Middle Name:ANN
Last Name:VAN DAM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 W KINGSBURY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-7710
Mailing Address - Country:US
Mailing Address - Phone:417-299-7602
Mailing Address - Fax:
Practice Address - Street 1:4870 W KINGSBURY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-7710
Practice Address - Country:US
Practice Address - Phone:417-299-7602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO686213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery