Provider Demographics
NPI:1528355153
Name:VAN BAAK, ALFRED A (MD)
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:A
Last Name:VAN BAAK
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:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:8300 CONSTITUTION AVE NE BLDG D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7613
Practice Address - Country:US
Practice Address - Phone:505-291-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-04
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2016-00512084N0400X
NMRS2011-0581390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07431210Medicaid