Provider Demographics
NPI:1962080689
Name:VANANTWERP, IAN (DO)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:VANANTWERP
Suffix:
Gender:M
Credentials:DO
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 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-8534
Practice Address - Street 1:701 N FIRST ST RM D442
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-1000
Practice Address - Country:US
Practice Address - Phone:217-545-0193
Practice Address - Fax:217-545-8156
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250787622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology