MEDICARE: DR. LORENE ANN VAN DAM DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0131X	Foot Surgery Podiatrist	686	MO

General Provider Information

NPI Number	:	1265588479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LORENE ANN VAN DAM DPM

Provider Business Mailing Address
First Line	:	4870 W KINGSBURY ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-7710
Country	:	US
Telephone Number	:	417-299-7602
Fax Number	:

Provider Business Practice Location Address
First Line	:	4870 W KINGSBURY ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65802-7710
Country	:	US
Telephone Number	:	417-299-7602
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2007
Last Update Date	:	06/10/2010

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