Provider Demographics
NPI:1174056980
Name:VAN, YVU
Entity type:Individual
Prefix:
First Name:YVU
Middle Name:
Last Name:VAN
Suffix:
Gender:M
Credentials:
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 626
Mailing Address - Street 2:
Mailing Address - City:GREAT RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11739-0626
Mailing Address - Country:US
Mailing Address - Phone:631-892-2745
Mailing Address - Fax:631-201-3179
Practice Address - Street 1:113 W ESSEX ST STE 202
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07607-1023
Practice Address - Country:US
Practice Address - Phone:201-845-6363
Practice Address - Fax:201-603-1993
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-07
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA12327200208200000X
CAA184635208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery