1003910522 NPI number — DR. MELVIN J VANBOVEN DO

Table of content: DR. MELVIN J VANBOVEN DO (NPI 1003910522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003910522 NPI number — DR. MELVIN J VANBOVEN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANBOVEN
Provider First Name:
MELVIN
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1003910522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-0303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-582-0001
Provider Business Mailing Address Fax Number:
918-582-0003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8803 S. 101ST E. AVE
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-582-0001
Provider Business Practice Location Address Fax Number:
918-582-0003
Provider Enumeration Date:
09/13/2006

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: 207ZP0102X , with the licence number:  1677 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 223073900 . This is a "DOL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 24563544102 , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100258170B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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