Provider Demographics
NPI:1770964413
Name:VANRYZIN, KIMBERLY JEAN (MD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JEAN
Last Name:VANRYZIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-963-2849
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD # B401
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-962-5975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11018313A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015016Medicaid