Provider Demographics
NPI:1730184193
Name:VAN DEVENTER, PAUL MATTHEWS (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:MATTHEWS
Last Name:VAN DEVENTER
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 1:2330 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6402
Mailing Address - Country:US
Mailing Address - Phone:985-674-1700
Mailing Address - Fax:985-674-1722
Practice Address - Street 1:2330 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6402
Practice Address - Country:US
Practice Address - Phone:985-674-1700
Practice Address - Fax:985-674-1722
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10083R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1531278Medicaid
LAG45763LMedicare UPIN
LA1531278Medicaid