Provider Demographics
NPI:1124048426
Name:VAN EGERAAT, JACQUELINE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:VAN EGERAAT
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:PO BOX 6020
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57709-6020
Mailing Address - Country:US
Mailing Address - Phone:605-342-3280
Mailing Address - Fax:
Practice Address - Street 1:101 E MINNESOTA ST
Practice Address - Street 2:SUITE 210
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7756
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD7260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS111653Medicare PIN
NE277060Medicare ID - Type UnspecifiedMEDICARE NUMBER