Provider Demographics
NPI:1831168624
Name:VAN DER HEIDE, DOUGLAS J
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:J
Last Name:VAN DER HEIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 E 85TH ST
Mailing Address - Street 2:5A
Mailing Address - City:NYC
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 E 85TH ST
Practice Address - Street 2:
Practice Address - City:NYC
Practice Address - State:NY
Practice Address - Zip Code:10028-0440
Practice Address - Country:US
Practice Address - Phone:212-772-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-15
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1312302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00509673Medicaid
NY00509673Medicaid
260051914Medicare PIN
NY28A441Medicare PIN
NY03355Medicare PIN