Provider Demographics
NPI:1063530749
Name:VAN, SHIRLEY LYNNE (MD)
Entity type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:LYNNE
Last Name:VAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1429 COLLEGE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4057
Mailing Address - Country:US
Mailing Address - Phone:209-526-2242
Mailing Address - Fax:
Practice Address - Street 1:1429 COLLEGE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4046
Practice Address - Country:US
Practice Address - Phone:209-526-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036164415207N00000X
CAG51607207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G516070Medicare PIN
CAA52035Medicare UPIN