Provider Demographics
NPI:1770576134
Name:VAN ANDEL, BRENT J (MD)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:J
Last Name:VAN ANDEL
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Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:EL CENTRO FAMILY HEALTH
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:711 BOND ST
Practice Address - Street 2:EL CENTRO FAMILY HEALTH BOND CLINIC
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2729
Practice Address - Country:US
Practice Address - Phone:505-753-9503
Practice Address - Fax:505-747-1004
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2013-07-01
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Provider Licenses
StateLicense IDTaxonomies
NM2004-0159207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMA100443OtherMEDICARE PTAN
NM99750040Medicaid
NMI12743Medicare UPIN