1932166741 NPI number — MIMI VAN DER LEDEN M.D.

Table of content: CARINA VALDEZ (NPI 1477226199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932166741 NPI number — MIMI VAN DER LEDEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DER LEDEN
Provider First Name:
MIMI
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1932166741
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3397
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60303-3397
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18425 CHAMPION FOREST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77379-3999
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-376-4410
Provider Business Practice Location Address Fax Number:
281-251-7505
Provider Enumeration Date:
04/26/2006

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: 207Q00000X , with the licence number:  L1227 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0045JQ . This is a "BCBS#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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