Provider Demographics
NPI:1023061934
Name:VAN DIVER, THOR WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:THOR
Middle Name:WILLIAM
Last Name:VAN DIVER
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:PO BOX 22005
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33742-2005
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-828-0723
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-823-2188
Practice Address - Fax:727-828-0723
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88143207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00407541OtherRAILROAD MCR LINKED TO GRP# CF4811
FL268026200Medicaid
FL81367OtherBCBS FL
FLP00407541OtherRAILROAD MCR LINKED TO GRP# CF4811