1023640448 NPI number — DR. LEONTINE JULIE VAN ELDEN MD, PHD

Table of content: DR. LEONTINE JULIE VAN ELDEN MD, PHD (NPI 1023640448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023640448 NPI number — DR. LEONTINE JULIE VAN ELDEN MD, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN ELDEN
Provider First Name:
LEONTINE
Provider Middle Name:
JULIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023640448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22 W 95TH ST APT 1R
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10025-6775
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
929-371-9077
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 YORK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10065-6007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-422-4922
Provider Business Practice Location Address Fax Number:
212-988-0683
Provider Enumeration Date:
02/05/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  301630 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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