Provider Demographics
NPI:1407654833
Name:VAN DAM, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:VAN DAM
Suffix:
Gender:
Credentials:
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 154068
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76715-4068
Mailing Address - Country:US
Mailing Address - Phone:254-399-8255
Mailing Address - Fax:
Practice Address - Street 1:560 E CENTRAL TEXAS EXPY STE 108
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-5625
Practice Address - Country:US
Practice Address - Phone:254-399-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist