Healthcare Provider Details

I. General information

NPI: 1962080689
Provider Name (Legal Business Name): IAN VANANTWERP DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N FIRST ST RM D442
SPRINGFIELD IL
62769-1000
US

IV. Provider business mailing address

PO BOX 19636
SPRINGFIELD IL
62794-9636
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-0193
  • Fax: 217-545-8156
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-545-8534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number82153-21
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number125078762
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: