Provider Demographics
NPI:1588872964
Name:ADAMS, VAN LEE (MD)
Entity type:Individual
Prefix:
First Name:VAN
Middle Name:LEE
Last Name:ADAMS
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 1:204 MALLOY ST STE A
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-4477
Mailing Address - Country:US
Mailing Address - Phone:919-751-7665
Mailing Address - Fax:
Practice Address - Street 1:204 MALLOY STREET
Practice Address - Street 2:SUITE A
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534
Practice Address - Country:US
Practice Address - Phone:919-751-7665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-02058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH310917085215OtherOHIO MEDICAID CARESOURCE
WV3810015431Medicaid
OH000000287236OtherOHIO MEDICAID UNISON
OH2969588OtherOHIO MEDICAID MOLINA
P00767040OtherRAILROAD MEDICARE
OH2969588Medicaid
OH000000287236OtherOHIO MEDICAID UNISON