Individual
THOR WILLIAM VAN DIVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
701 6TH ST S, ST PETERSBURG, FL 33701-4814
(727) 823-2188
(727) 828-0723
Mailing address
PO BOX 22005, ST PETERSBURG, FL 33742-2005
(727) 823-2188
(727) 828-0723
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
ME88143
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
268026200
—
FL
01
—
81367
BCBS FL
FL
01
—
P00407541
RAILROAD MCR LINKED TO GRP# CF4811
FL
Enumeration date
05/19/2006
Last updated
10/05/2010
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