Provider Demographics
NPI:1053431965
Name:VAN LOON, GERRIT III (DC)
Entity type:Individual
Prefix:
First Name:GERRIT
Middle Name:
Last Name:VAN LOON
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SHARLENE RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-6315
Mailing Address - Country:US
Mailing Address - Phone:607-277-1468
Mailing Address - Fax:607-277-1468
Practice Address - Street 1:103 SHARLENE RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-6315
Practice Address - Country:US
Practice Address - Phone:607-277-1468
Practice Address - Fax:607-277-1468
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8425225100000X
NY006650111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000916364001OtherHEALTH NEW - CHIRO
NY000916364001OtherHEALTH NEW - CHIRO
NY55597AMedicare ID - Type UnspecifiedMEDICARE
NY000915146001OtherHEALTH NEW - P.T.