Provider Demographics
NPI: | 1811242381 |
---|---|
Name: | VAN SCHALKWYK, GERRIT IAN (MD) |
Entity type: | Individual |
Prefix: | DR |
First Name: | GERRIT |
Middle Name: | IAN |
Last Name: | VAN SCHALKWYK |
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: | PO BOX 27128 |
Mailing Address - Street 2: | |
Mailing Address - City: | SALT LAKE CITY |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84127-0128 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 5770 S 1500 W |
Practice Address - Street 2: | |
Practice Address - City: | TAYLORSVILLE |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84123-5216 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-313-7770 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2012-07-19 |
Last Update Date: | 2021-10-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 053229 | 2084P0804X |
UT | 11866360-1205 | 2084P0804X, 2084P0800X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |