Provider Demographics
NPI:1447269451
Name:WOELTZ, VAN M (MD)
Entity type:Individual
Prefix:DR
First Name:VAN
Middle Name:M
Last Name:WOELTZ
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 1:1532 LONE OAK RD STE 150
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-7940
Mailing Address - Country:US
Mailing Address - Phone:270-538-6700
Mailing Address - Fax:270-538-6755
Practice Address - Street 1:1532 LONE OAK RD STE 150
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7940
Practice Address - Country:US
Practice Address - Phone:270-538-6700
Practice Address - Fax:270-538-6755
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY877432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.92535OtherIL LICENSE
ILIL1391OtherPTAN
KY64877434Medicaid
IL036.92535OtherIL LICENSE
ILIL1391OtherPTAN
KY64877434Medicaid
KYP00026671Medicare PIN