Provider Demographics
NPI:1780622811
Name:VAN WYK, CHARL STANHOPE (MD)
Entity type:Individual
Prefix:
First Name:CHARL
Middle Name:STANHOPE
Last Name:VAN WYK
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 1:800 ROSE ST
Mailing Address - Street 2:HX311
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-2379
Mailing Address - Country:US
Mailing Address - Phone:859-323-5069
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:HX311
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-2379
Practice Address - Country:US
Practice Address - Phone:859-323-5069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY392882085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2591039Medicaid
WV3810002596Medicaid
KY64092455Medicaid
OH2591039Medicaid
0929144Medicare ID - Type Unspecified
WV3810002596Medicaid