Provider Demographics
NPI:1932166741
Name:VAN DER LEDEN, MIMI (MD)
Entity type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:VAN DER LEDEN
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 3397
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60303-3397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18425 CHAMPION FOREST DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-3999
Practice Address - Country:US
Practice Address - Phone:281-376-4410
Practice Address - Fax:281-251-7505
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0045JQOtherBCBS#
TXG63042Medicare UPIN
TX00294VMedicare ID - Type UnspecifiedMEDICARE #