Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | 004019 | GA |
Y | 207N00000X | Dermatologist | 067449 | GA |
NPI | 1023262185 |
---|---|
Provider Name | Dr. Livia Van |
First Address | Atlanta, GA 30305-1717 |
Second Address | Jonesboro, GA 30236-2500 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2008 |
Last Update Date | 21/12/2021 |