Provider Demographics
NPI:1356532709
Name:VAN, THU (OD)
Entity type:Individual
Prefix:DR
First Name:THU
Middle Name:
Last Name:VAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7420 PALM BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72019-2023
Mailing Address - Country:US
Mailing Address - Phone:501-329-2020
Mailing Address - Fax:
Practice Address - Street 1:1155 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-2857
Practice Address - Country:US
Practice Address - Phone:501-329-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2587152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR167610722Medicaid
4T004Medicare PIN