Provider Demographics
NPI:1639119860
Name:VAN RAVESTEYN, JAN A (MD)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:A
Last Name:VAN RAVESTEYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-262-7901
Mailing Address - Fax:704-262-7902
Practice Address - Street 1:304 WINECOFF SCHOOL ROAD
Practice Address - Street 2:WINECOFF FAMILY PRACTICE
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027
Practice Address - Country:US
Practice Address - Phone:704-262-7901
Practice Address - Fax:704-262-7902
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1208VOtherBCBS
NC891208VMedicaid
NC1208VOtherBCBS
G90608Medicare UPIN
NC891208VMedicaid