Basic Information
| Provider Information | |||||||||
| NPI: | 1447269451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOELTZ | ||||||||
| FirstName: | VAN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1532 LONE OAK RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705386700 | ||||||||
| FaxNumber: | 2705386755 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 LONE OAK RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705386700 | ||||||||
| FaxNumber: | 2705386755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 87743 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 036.92535 | 01 | IL | IL LICENSE | OTHER | IL1391 | 01 | IL | PTAN | OTHER | 64877434 | 05 | KY | MEDICAID |