Healthcare Provider Details

I. General information

NPI: 1730108788
Provider Name (Legal Business Name): JOHN NICHOLAS VAN DAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5801 ALLENTOWN RD STE 400
CAMP SPRINGS MD
20746-4585
US

IV. Provider business mailing address

8116 GOOD LUCK RD STE 305
LANHAM MD
20706-3508
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-0150
  • Fax: 301-868-0243
Mailing address:
  • Phone: 301-552-1200
  • Fax: 301-552-2611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD11962
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD30583
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: