Provider Demographics
NPI:1871515106
Name:VAN DOREN, THOMAS H (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:H
Last Name:VAN DOREN
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 1:5320 HOLIDAY TERRACE, SUITE E
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-353-3503
Mailing Address - Fax:269-353-3655
Practice Address - Street 1:5320 HOLIDAY TER STE E
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2100
Practice Address - Country:US
Practice Address - Phone:269-353-3503
Practice Address - Fax:269-353-3655
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITV0337442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI039 4551Medicare ID - Type Unspecified
MIB46484Medicare UPIN